Shame is the capacity to suffer under the gaze of the other. The other can be anyone, even oneself; we’re perfectly able to feel wounded by our own perceptions. There’s also a certain pride in shame—as proof of moral rectitude, of earnestness, or of competence. A patient learns that he will eventually go blind; it takes a year for him to confess this news to his family. He feels ashamed, and at the same time, he feels proud to suffer in silence. Shared emotion brings relief to the afflicted, yet it propagates his suffering; and by what right do I pass on my pain to my loved ones?

I think about this on a park bench, with a bottle of pineapple juice on one hand and no intention of calling my family. Not wanting to propagate my suffering is an excuse; if I die, my family’s pain will be far greater.

It’s the loser’s shame, then. If I pass out, I lose. Who am I if I can’t keep my blood sugar under control? You shouldn’t have eaten that bowl of ramen. It’s your responsibility. There’s this dog lying on a patch of grass in front of me, and he’s still yawning, and I desperately want to pet it. I want to tend to a garden. I haven’t been able to get out of the city yet; I’d love to go for a hike, to lose myself on some trail, to be part of a nature-driven epiphany that makes me understand how the world works and calms me down and makes me accepting of my illness, turns me into a placid, kind-eyed monk.

But I’m sitting on this bench and I can’t feel my legs, I’m sweating and panting and I can barely see. How am I supposed to play cool independent adventurer in the woods? I hear there are bears. I picture a bear yawning, and I hoist my two-liter bottle of juice to take another swig.

An illness is also a healing balm, an unguent—especially if it is socially accepted. It serves as fertile ground; it mothers your identity; it bears fruit and takes root. One benefits immensely from one’s illness; indeed, some are so eager to have one that they craft their own. They build slowly, with care. They decorate. They perform. To be ill is to be a victim, and that notion proves delightfully relaxing. Guilt is drawn out of you and replaced by a certain calmness that feels as protective as it feels alienating.

My diabetes is my greatest, most beloved excuse. It never fails. My diabetes removes me from the equation, cancels me out. My diabetes drops me inside a limbo, a liminal space. Why do I call it mine? It punishes and rewards me. It’s my biggest bet against shame; whenever the dreaded feeling bubbles up, I can use my glucose levels to run and hide, to defend myself, to set up a smokescreen.

It’s part of the intricate fabric of my body-mind, perhaps even of my soul. Yet there was a time, nebulous and distant, when I was not diabetic. I barely remember it. Was that truly me back then? Have I been two different people? I’d feel naked without my glucose monitor and my insulin pump. Every shift within my mind, every movement of my body, every lighting up of every neuron affects my illness, and my illness, in turn, influences every cell that thinks and feels. I cannot exist separately from my hypoglycemia.

Even worse so: will I ever be able to exist without shame? Shame precedes even my autoimmunity; shame has always been there. If everything’s interconnected, then I’m forced to admit that shame played a defining role in the development of my illness. It’s also playing a role in my losing consciousness; it gives and takes away.

I drink and stare at the dog. I think I’d like him to be the last thing I see. It’s a good final image. But then… what if I’m exaggerating? Maybe this is nothing and I’m making a complete fool of myself for believing I’m about to drop dead and miss out on all the beauty of life—oh, the tragedy!—and maybe this yawning dog is just a dog and not my last impression of the world and the epitome of tender simplicity.

Those who are ashamed are very good at being victims, but they will also try their best to be caregivers. Helping another wounded soul proves I’m not quite so miserable myself. Service to others is a weapon I can wield; to fight against the meaninglessness of my existence and to show I have a right to be here. My diabetes grants me the people’s pity, and unlocks a new perspective, that of the chronically ill: a vantage point to which the majority have no access. Illness touches us all, just as life does; yet autoimmunity and degenerative ailments, inevitable and relentless, are not, fortunately, a shared experience for our species. This means that there are certain things, certain feelings or ways of coping, that only us, the permanently sick, can understand. Cold comfort, I know. But to carry the bodily wisdom of a chronic ailment, to feel it, deeply and daily, carving and scarring, should also make me capable of great empathy, of great compassion.

It does not. I’d be a wonderful caregiver if I wasn’t wholly corrupted by the urge, the desperate desire to exist solely within the gaze of others. The image in their minds is more powerful than the present moment in which I live, and stronger than the reality I could build for myself. Shame is the guiding factor in all this; it turns real people into members of an audience, and one cannot fail in front of an audience. One cannot show oneself, one needs to win approval. To really care for someone includes, necessarily, that you be vulnerable and open, genuine and honest. If what I want is for others to perceive me as a caregiver, then I’ll never actually become one.

Once again, the problem lies in my inability to step outside myself.

Web image by Riley Revell 

Narrative

Isles

José Luis Marín Aznárez 05.11.26

Illness, emotion, story, and the interconnectedness of it all; a meditation on a park bench, on the verge of death

Back when I was doing my internship at Pennsylvania Hospital, I was so surrounded by history I felt like I was working in a museum. Even the china we dined on in the hospital cafeteria sported the original historic pattern. And when we finished our training, a brass plaque with our names went up on the same wall as the plaques of our predecessors going back to the 18th century.

At the time, none of this was widely known. But fortunately, Pennsylvania Hospital now has an actual museum, open to the public just in time for the nation’s 250th anniversary. The Pennsylvania Hospital Museum is compact yet chock-full of art, architecture, artifacts, and documents, and has at once become a must-see destination in Philadelphia.

Although Bellevue Hospital has roots that go back to 1736, it started out as an almshouse. Pennsylvania Hospital was the first institution in the colonies founded specifically as a hospital, established in 1751 by Benjamin Franklin and Thomas Bond. The 1756 building housing the museum is a National Historic Landmark. Not only is it considered an important example of Georgian architecture, but its cornerstone even bears an inscription by Franklin referring to King George II.

The landscaped grounds are a serene oasis in the middle of Philadelphia’s Society Hill neighborhood and include a Physic Garden containing herbs and plants used for medicines in the 18th century.

As one enters the building, the first room encountered is the pharmacy, which remained in use until 1927 and now contains interactive displays. A fire engine purchased in 1803 sits in the foyer at the base of a grand staircase. After ascending to the second floor, visitors enter America’s first medical library, a handsome wood-paneled room containing more than 13,000 volumes from floor to ceiling, including one of the nation’s most complete collections of medical books published between 1750 and 1850.

The third floor houses the nation’s oldest surgical amphitheater. In the era before electricity, it was illuminated by skylight, so surgeries could only be performed on sunny days. (I must confess that we interns used to sneak into this room when on call. It was spooky in the middle of the night!)

For me, as a psychiatrist, the highlights of the museum were the exhibits on mental health. I have previously written in MedHum about Benjamin Rush, often called the father of American psychiatry, whose portrait is on view here. Rush served on the staff at Pennsylvania Hospital from 1783 until 1813 and was known for his groundbreaking and humane treatment of the mentally ill. Metal shackles once used as restraints are also on display, although hopefully they predated Rush’s tenure.

Another psychiatric pioneer whose portrait hangs in the museum is Thomas Story Kirkbride, who came to Pennsylvania Hospital for residency training in 1834. When the psychiatric wards exceeded capacity and a satellite facility was built on 101 acres in West Philadelphia, Kirkbride was named superintendent. His ideas about the layout and design of mental institutions became highly influential, leaving an imprint on hospitals throughout the country.

Initially called the Pennsylvania Asylum for the Insane, the new campus eventually became known as the Institute of Pennsylvania Hospital. I completed my residency training there, but over time it was no longer financially viable, and it closed in 1997.

How fascinating to learn that Francis Scott Key, of “The Star-Spangled Banner” fame, wrote a poem titled On Visiting the Pennsylvania Hospital. And to see 18th-century anatomical casts used for teaching at a time when formal dissection was illegal.

There is so much history in this museum that I could not absorb it all in one visit. With its addition, Philadelphia further demonstrates its role as the cradle of American medicine. Indeed, one would have to travel to London to find a larger assemblage of medical historical sites.

In one very busy day—or a more leisurely two-day trip—a visitor can now experience this museum, plus the College of Physicians of Philadelphia and its famous Mütter Museum, while also stopping to see The Gross Clinic by Thomas Eakins. (The painting alternates between the Philadelphia Museum of Art and the Pennsylvania Academy of the Fine Arts, but will spend 2026 at the latter.)

Bravo, Philadelphia!

Benjamin Rush:  Reflections from a Psychiatrist 

Guy Glass 09.02.24 0

A founding figure in American psychiatry, known for pioneering reforms, but also controversial for his treatments and complex contradictions in beliefs and practices.

For more information about the museum, visit Pennsylvania Hospital Museum.
Web image from Wiki Commons

Hypoglycemia can kill you fast. The brain, our most self-centered organ, is also the greatest consumer of glucose. If blood sugar levels drop, it starts to shut down the rest of the body, in a desperate attempt to save fuel —it will drink every last drop of sweet sustenance before collapsing.

That’s how it feels; like parts of me slowly go dark. If I collapse, right here, in the middle of this park, I won’t have had a chance to say goodbye.

It’s a beautiful day outside. Beneath the trees, the filtered light takes on a greenish hue. A dog yawns on a patch of grass in front of me. I’ve found a spot on the corner of a bench facing a fountain—I can barely see it though, given the sheer number of people coming and going, dodging one another and getting in the way. I rub my right hand against my thigh, starting from the knee, pressing down with my thumb. I look around and crane my neck, trying to scrunch it down over my shoulders like an accordion.

I need to drink this entire bottle of pineapple juice. I bought it at a street stall the moment my alarm went off. Something must have gone wrong—with my meal, with the heat, with my nerves, or with who knows what, but my blood sugar is draining away, slipping right out of my body. Within the nebula that is my mind, clusters of stars begin to vanish. Suddenly, in a corner, the light goes out. A void emerges in the upper-left quadrant; I lose an immense cloud of hydrogen, and, along with it, all sensation in my feet. Blinking becomes a conscious task that demands effort; I don’t want to make it, so I simply close my eyes as I drink. There dies a sun, leaving its entire solar system in complete darkness. My hand has already made a hundred trips up and down my thigh. It occurs to me that all this back-and-forth motion is burning glucose, but the movement helps keep my anxiety at bay. Fighting this panic is costing me the very sugar I don’t have; I am living proof (at least for now) that sometimes, resisting the inevitable only makes things worse. If you fall into quicksand, stay still.

Someone shouts, somebody laughs and claps; there’s people making music, but it’s all distorted, as if the hot air were making the sounds bubble. I hear the beep of my insulin pump. It hasn’t stopped vibrating; I pull it out from my pocket and imagine it’s screaming at me, threatening me. My sugar levels are very low, and they’re still plummeting. The app on my phone—connected to the glucose monitoring patch on my arm—picks it up, too: my screen turns crimson, filled with arrows pointing straight down. I don’t have much time.

At least I’m sitting down, though I doubt I could stand. I think about calling an ambulance, but I suspect that if I had to start speaking to explain the situation, my voice would sound like a soaking-wet mop dragging across a school hallway floor. Besides, wouldn’t it be better to call my mother? Or my father, or my siblings—or the girl I dated a couple of years ago? Because I’ve only ever managed to fall in love once, with her; what a waste it would be if I died here, alone in a park bench. I’d lose the chance to experience that feeling again.

I should tell my mother that I love her, but there’s a six-hour time difference between New York and Madrid, so she’ll be asleep; and honestly, I don’t think I have the time or energy left to unlock my phone and make the call. I ought to keep drinking. The more pineapple juice I gulp down, the higher my chances of survival. I’ve never really known exactly when a person loses consciousness and slips into a coma—I don’t know how close I am to that edge. I don’t know how far away those thresholds lie, or how quickly they’re being crossed. I want to call someone, or cry out for help, or at least make sure that someone sees me losing consciousness—if only so I can say that someone was there, that someone witnessed it. That they saw the sun go out.

I don’t do it. I move only my arm; I bring the juice to my lips. My fingers tingle. I tremble.
A blink of an eye lasts longer than before.

I stare at a shapeless, unfocused mass of people. There’s this phase in hypoglycemia in which I feel myself reverting to something animalistic, primitive, a beast between two palm fronds; I’m in awe of the certainty I feel that nothing matters except my own survival.

An example: I drag my body to the fridge, haul myself forward, shove everything into my mouth without thinking; juice and Coca-Cola drip down my chin; I mix bread and fruit and cheese and sauces and whatever else I find; I use my hands—tearing, shredding, and stuffing it all into my mouth—barely chewing, coughing and spitting, then swallowing again; my fingers slick with grease. A ravenous urge burns across my forehead, and I breathe with incredible depth, as if someone were pumping oxygen into me through a funnel embedded in my throat.

I remember having done that several times.

I exhale, emptying myself out, and sparks fly from between my teeth. I can’t see clearly. Things—people? —move before me, but they’re terribly blurred. It doesn’t matter; I’m the center of the universe. I’m like a child. I drink my juice.

The feeling of losing control is a curious one, for it seems to be well-organized. From the bottom up, my limbs go numb. Mental fog seeps in through my nose and settles in my glabella. It concentrates; crystallizes. My thoughts cease to be mine—though I wonder if they ever truly were—and questions of this sort—like the one about love—begin to bubble up. Flashes.

Suddenly, I find myself wondering if I have ever truly been rebellious. I don’t know. My mother used to say that as a baby, I never cried—that I was pure tenderness. The thought of dying fills me with distress, for tenderness makes everything interesting, and I long to hold a little girl in my arms—to know that she’s my daughter, to watch her cling to me, burying her fingernails into my skin, like tiny half grains of rice. I tell myself that this is my life’s dream and purpose; for a moment, it feels as though my body might finally be able to relax—but it doesn’t. There remains a starry corner of my mind that still clings to the juice, to the park, to the yawning dog, and to reality itself. I take another sip.

A sudden flash: a line from a John Ashbery poem that says the bedroom of the soul is our moment of attention. I force myself to pay it— I tell me that, in doing so, I’m bringing myself back to consciousness. A minute’s passed? Or is it already the next day? I can’t tell.

Tachycardia is the worst part, for it forces itself upon me. It tramples my chest, imposing a rhythm of time from which there’s no escape. The only thing I can feel is my heart.

A hundred beats.
Hundred and twenty.
Hundred and forty.

Panic and tachycardia are close allies —and panic is a diabetic’s sworn enemy. It wants to trick me, it whispers, tells me everyone’s watching me, says all can hear the frantic hammering in my chest. Random clusters of thought dissolve, giving way to a single, definitive question. It is here that my illness bifurcates, and I ask myself (as I’ve been doing for years): which comes first, diabetes or shame?

I don’t dial 911, I don’t call my family, and I don’t ask for help, because I am ashamed. Right now, on the verge of losing consciousness, nothing should matter except staying alive. I ought to scream, to make a scene; for if I simply let myself fade away while sitting on a bench in the middle of Washington Square Park, no one is going to stop and help me. New Yorkers are more than used to seeing people sprawled on the ground, asleep on benches, or passed out in the subway; they won’t be the least bit fazed to stumble upon a twenty-something year old with his head lolling and his eyes closed, sitting upright, back straight, clothes clean, beard neatly trimmed. I need to grab their attention—my life’s slipping away, my blood feels as if it’s being pulled downward—I have to do something, right here, right now, but I can’t.

Asking for help means intruding on another person; it means meeting their gaze, making demands, stepping out into the spotlight to take a bow before the entire audience. It is here, in this theater of interaction, where human beings are made and molded. In my case, the guiding emotion is shame. The gaze of the other is the place where we all live and die. What is it, then? What’s about to kill me? Hypoglycemia, or my own inability to step outside myself?

Web image from Wiki Commons.

The time has come when the existence of a private pestilence in the sphere of a single physician should be looked upon, not as a misfortune, but a crime; and in the knowledge of such occurrences the duties of the practitioner to his profession should give way to his paramount obligations to society.

— Oliver Wendell Holmes, “The Contagiousness of Puerperal Fever”

It would have been cold on February 13, 1843, when the Boston Society for Medical Improvement convened. But anyone who heard Oliver Wendell Holmes’s fiery speech about puerperal fever would have forgotten about the chill outside immediately.

Holmes stood just 5’ 3”. And he was young, only 34 years old. But he was hot with moral authority. He was so sure that puerperal fever was contagious that he accused his skeptical colleagues of murder. He knew that in order to make them listen, he had to do more than lay out the facts. He needed a persuasive story.

As I’ll show presently, it was precisely this approach that allowed Holmes to win Nathaniel Hawthorne’s trust as personal physician to the great author near the end of his life. No mean feat, since Hawthorne was terrified by medical science.

The Crowd Puller

In those days, you had to speak well publicly to make a name for yourself. Oratory was required in school. In New England, the rhetorical standard was set in the pulpit, and public discourse followed. So it wasn’t an insult if someone said your speaking or writing felt sermon-like. Good sermons could awaken, convict, inspire, and transform even the most uneducated souls. The best professors and the best doctors fit the ministerial mold.

In New England, good speakers were a dime a dozen. But Holmes stood alone.

One of Holmes’s students recalled how he could hold a crowd:

He always makes people attentive, and I have been told that there is no professor whom the students so much like to listen to. In one of his books he says that every one of us is three persons, and I think that if the statement is true in regard to ordinary men and women, Doctor Holmes himself is at least half a dozen persons. He lectures so well on anatomy that his students never suspect him to be a poet, and he writes verses so well that most people do not suspect him of being an authority among scientific men.

This was also a time when science was retreating from the public sphere. Hawthorne was writing short stories about the terrors of the lab, where Rappaccinis and Chillingworths played God. As Michel Foucault said, it was a time when some doctors took the patient into account “only to place him in parentheses.”

Holmes was a scientist, but he hated how science made some of his peers “think only in single file.” And so he tried to wake his colleagues up on that cold day in Boston with facts, but also with panache and metaphor.

The Case for Contagion

Attention spans were different in 1843. The full text of Holmes’s speech, which he later published in essay form, was over 12,000 words. It would have taken him at least an hour to deliver it. He had to review many cases in depth, not just spin fetching tales.

But that’s why everyone in the Boston Society had gathered that day. They wanted to get better as doctors, for medicine itself to improve. So they listened.

Holmes points out that William Dewees’s A Treatise on the Diseases of Females, published in Philadelphia in 1833, explicitly denies that puerperal fever is contagious and that the Philadelphia Practice of Midwifery (1838) omits mention of the disease entirely.

Unthinkable now, but it was commonplace for a doctor or midwife to deliver one baby and then move to the other without washing their hands. Holmes’s words for such a physician? A “death-carrying attendant.”

He also opens with a logical list, a kind of syllogism, something he’d have learned from his humanities education. If all these things are true, then there’s no room left for opposing views.

1. Not all forms of puerperal fever may be equally contagious. But evidence shows the disease appearing again and again among patients of a single practitioner, even when no epidemic is present. That pattern demands explanation.
2. Whether infection travels through the air a physician carries into the sick-chamber or passes directly from his unwashed hands, the practical result is the same. We need not settle the question to act on it.
3. Contagion does not guarantee infection. Even the smallpox vaccine, fresh and carefully administered, sometimes fails. Same for scarlet fever. But no one doubts those diseases are contagious.
4. Seasonal and regional influences may trigger or worsen the disease. But smallpox follows the same patterns of rise and fall, and no one doubts it spreads by contagion. Why should puerperal fever be different?
5. If physicians can be shown to carry death instead of health, no excuse will absolve them. “[W]henever and wherever they can be shown to carry disease and death instead of health and safety, the common instincts of humanity will silence every attempt to explain away their responsibility.”

It made Holmes angry that colleagues could explain the deaths of new mothers as Providence, using God’s will as an excuse for their own failures to stop preventable deaths. 

We do not deny that the God of battles decides the fate of nations; but we […] are particular that our soldiers should not only say their prayers, but also keep their powder dry. We do not deny the agency of Providence in the disaster at Norwalk, but we turn off the engineer and charge the Company five thousand dollars apiece for every life that is sacrificed. Why a grand jury should not bring in a bill against a physician who switches off a score of women one after the other along his private track, when he knows that there is a black gulf at the end of it, down which they are to plunge, while the great highway is clear, is more than I can answer.

I’ll not reprise Holmes’s full review of cases (he painstakingly covers more than half a dozen). You can read the full text that he reprinted in Medical Essays here.

What I want to emphasize is how storytelling was much more than a way to “sell” science for Holmes. He knew that story piqued an emotional understanding of science, which was how doctors could be persuaded to act, and also how public trust could be earned and held.

Here’s his passionate conclusion in full:

It is as a lesson rather than as a reproach that I call up the memory of these irreparable errors and wrongs. No tongue can tell the heart-breaking calamity they have caused; they have closed the eyes just opened upon a new world of love and happiness; they have bowed the strength of manhood into the dust; they have cast the helplessness of infancy into the stranger’s arms, or bequeathed it, with less cruelty, the death of its dying parent. There is no tone deep enough for regret, and no voice loud enough for warning. The woman about to become a mother, or with her new-born infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her aching limbs. The very outcast of the streets has pity upon her sister in degradation when the seal of promised maternity is impressed upon her. The remorseless vengeance of the law, brought down upon its victim by a machinery as sure as destiny, is arrested in its fall at a word which reveals her transient claim for mercy. The solemn prayer of the liturgy singles out her sorrows from the multiplied trials of life, to plead for her in the hour of peril. God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly!

I read recently that we respond much more powerfully to troubled characters in fiction than we do to stock types who move from one adrenaline-spiked obstacle to the next. That’s because our deepest emotional responses are driven by three chemicals (dopamine, cortisol, and oxytocin). These brain responses are strongest when we truly care about someone else.

Holmes was trying to do something similar by creating a moral dilemma within the physicians he addressed. The doctor who cared nothing about exposing his patients to risk had no soul. But the doctor who could imagine a family’s grief and wrestle with his own culpability was more complex, more colorful, more worthy of trust.

If you’d been listening to Holmes on that February day, you know which doctor you’d have wanted to be.

Converting the Chief Skeptic

Despite his charms, it took time for Holmes to push his reforms. People thought he looked too young. One woman ordered him out of her house when he accompanied a senior physician during his medical training. “Take him away!” she cried. “This is no place for boys.”

Holmes’s colleagues respected his medical skill, but thought him “impaired” for writing poetry. And not all readers of The Atlantic loved him. To some he was a “tiresome little man.”

As one biographer explains, Holmes “disarmed criticism…by courageously persisting in the same method which had originally produced it, namely, by the most fearless intimacy with his audience, never keeping back any jest or any expression of confidence.” In a word, he was not afraid to make himself vulnerable in his writing. 

Holmes and Hawthorne shared pages in The Atlantic Monthly and also knew each other through the Saturday Club, a gathering of literary celebrities that included Ralph Waldo Emerson, Henry Wadsworth Longfellow, and Harriet Beecher Stowe hosted by the publisher James T. Fields. Hawthorne was quiet and shy, brooding around the edges, but Holmes loved to regale the group. As Annie Fields recalled, “with Dr. Holmes sunshine and gayety came into the room.”

The two writers developed a close intellectual relationship, commenting on each other’s manuscripts and commiserating with one another over the dangers of pseudoscience and careless experimentation. So it was no surprise that when he grew ill in 1864, Holmes was the only doctor that Hawthorne would see. Hawthorne had watched a friend die of pneumonia while a quack prescribed a variety of ineffective drugs, poultices, even cupping and blistering, to no avail.

As the two men walked the Boston streets, Holmes conducted a “talking exam,” listening while Hawthorne reported his symptoms of indigestion and fatigue. Holmes recognized that Hawthorne suffered from a profound sense of despondency which signaled imminent death, that there was no cure but compassion. This was an intimate moment—as vulnerable as the introverted Hawthorne had ever allowed himself to be with anyone—and it illustrates Holmes’s ability to reassure even this great skeptic of his good intentions. 

Hawthorne’s simultaneous fear of alternative medicine and medical science left him nowhere to turn as his own death approached. On the one hand were the mesmerists who sought to control the individual through pseudoscientific means. On the other were the Rappaccinis whose misappropriation of science was equally hostile to the privacy of the soul.

Only Holmes could rescue Hawthorne from those two nightmares. He did it as a man of science, as an indefatigable optimist, as a caring friend, and, yes, as a storyteller who knew that passion is one form of understanding.

Web image of A young Oliver Wendell Holmes from PBS.

In 2019, a prominent obstetrician/gynaecologist in Toronto was found guilty of administering intravaginal medications to his obstetrics patients for the purposes of inducing labour without consent. He was subsequently dismissed from his position at the hospital and his career ended. The story was covered in detail in an exposé published in Toronto Life magazine. 

The details of the case are lurid. In the modern age, most obstetricians do group call. Gone are the days when an expectant mother would have both her prenatal care and delivery done by the same physician. Newborn babies are wont to arrive in the world at any given moment, and the traditional obstetrician who drops everything they are doing to attend these deliveries, often in the middle of the night and often with a full day of office work the next day, is all but extinct. Obstetricians now share call duties with a team of physicians. Now, when you sign up with a certain obstetrician, there’s no guarantee that that specific doctor will be the one to deliver your baby, only that someone from their group will be doing the delivery. 

In Ontario, obstetricians are paid more for delivering babies on weekends than they are on weekdays. It’s a nice little reward for doctors who usually work long and unpredictable hours. But in this one hospital, the obstetrics department began to notice that one of their staff had a propensity for babies being delivered predominantly on weekends and evenings and began tracking the matter. 

In time, they discovered that this doctor was inserting tablets of misoprostol into the vaginas of late term pregnant patients in order to induce labour on specific days that were to his advantage, often when the date in question was a weekend. Misoprostol has the ability to induce contractions and is often used in medical abortions. It is not considered to be a medication safe to use in pregnant women to induce labour on command. Needless to say, the patients did not give informed consent for the procedure, nor were they offered the option to decline.The doctor in question was a prominent member of Toronto’s Chinese Canadian community. He had a reputation for being a doctor to the rich and chic. Famous Hong Kong celebrities flew to Canada to have their babies delivered by him and my own patients flocked to him in droves. 

In Toronto, getting a referral to a community obstetrician of choice to deliver your baby is like trying to get your child into an elite private school–no doubt, these actions are often being done by the same parents, just a few years apart. Obstetricians have a set number of expectant mothers they can carry for any given month and once that quota is exceeded, they can’t accept any more patients. In those years when I first started working as a family physician, Chinese immigrant women in my community knew to race to our office as soon as they suspected they were pregnant, so as to get into the front of this doctor’s queue. They were then told by the obstetrician’s office that they were expected to pay a three-hundred-dollar administrative fee in order to guarantee this doctor would be present for the delivery, which they gladly paid.^⁠1 

At the time, it seemed reasonable. Three hundred dollars and your doctor would buck the modern trends of group call and shared team duties and promise to come in on his night off to personally deliver your baby. It all seemed legitimate and altruistic, a call back to a simpler time. If only. 

When the story broke, there was the expected furor in the local medical community. Certainly, the salacious nature of the case, the prominence of the doctor in question, the #MeToo movement which was also taking place around this time, gave the story its pull. 

In the local Chinese community, the story had buzz as well. Toronto, with its large Chinese-speaking population, has several Chinese daily newspapers and the story made headlines in the local Chinese newspapers and filtered its way through all of us. It felt like everyone’s mother had heard of this doctor; he was that well-known. 

As I spoke to patients and friends and colleagues, I discovered so many people around me had had their children delivered by this doctor in the preceding decades. As they reflected on their obstetrics journeys, the stories were all the same. Yes, it was true, many of their babies had happened to arrive on a weekend. Yes, the labour started soon after an assessment, right on schedule and with what had seemed like fortuitous timing at the time. Now, in retrospect, it all seemed fishy and possibly sinister. 

But one thing that I noticed was that this doctor’s actions were met with largely a collective sigh of indifference by the Chinese Canadian community. The lack of outrage most people had towards the story felt odd. Remember, this story was occurring near the height of the #MeToo movement. The idea of a doctor administering intravaginal medications without consent should have, in the West, been seen on the level of battery. At the very least, I expected people to think of it as a violation of a woman’s body. But in the Chinese community, amongst the population that knew this doctor the best, the reaction was muted. Most of his patients that I encountered shrugged off the story. When the subject came up, they were quick to point out to me that he was an outstanding doctor who had helped many people and were disappointed to hear that the doctor was no longer practising. 

In China, women’s reproductive rights is an issue with a thorny history, especially over the last several decades, most of which I was oblivious to until I started working with my own patients. 

The most blatant and obvious reproductive rights issue is China’s One-Child Policy, which ran from 1979 to 2015. During these years, families in China were limited to having only one child, except in special circumstances. The One-Child Policy was formulated in response to the Chinese government’s fear of overpopulation. 

In my naive understanding of China, I was taught the official narrative, that people who had more than one child were subject to higher rates of taxation, and it was the punitive toll of this taxation that kept parents in line. 

But the truth was more complex. What were people’s expectations about birth control? What happened when people didn’t agree with the government’s policy? What happened to people who had an extra child on purpose? What happened if they had a child accidentally?  

When I started working, I soon noticed that all middle-aged women from mainland China had intrauterine contraceptive devices implanted in their uterus. Mostly, they had had these devices placed after delivering a baby years earlier. In many cases, these IUCDs had been present in these patients’ uterus for so long that many of them often forgot to mention it to me, only informing me about the presence of these devices sometimes when they were in their late fifties or early sixties, long after the device had ceased to perform any useful function. Often times, we’d discover that these devices were present during a routine ultrasound, and the patient would remember that yes, they had been wearing an IUCD for so long that they had simply forgotten about it–it had simply become a part of them. This wasn’t an entirely benign situation. The longer an IUCD remained in, the greater the chance it would slowly embed into the tissue of the uterus. Albeit rarely, there are case reports of it rupturing the uterus of women after decades being left in. 

Even after I realized that so many of my patients were wearing IUCDs, I still didn’t fully understand what this meant. I had in my mind envisioned the Western model of women’s reproductive care, that the mother had informed her obstetrician in China at some point after the delivery that she would have an IUCD inserted because yes, she was certain she didn’t want to have another child for a few years. I envisioned a long conversation where a medical professional gave the patient a series of options about contraceptive care. Did the patient want an IUCD? Or maybe to try the birth control pill? Or did the patient want to use natural family planning methods? It was only gradually that it dawned on me, that these were conversations we only had in the West, not conversations women had in China. They weren’t given the option of having an IUCD inserted. They were simply told what to do, or had it done unto them. 

But my women patients didn’t seem bothered by this. They never expressed outrage at having an IUCD. It was again, the collective shrug of indifference. It wasn’t that different than being told that they had to pay taxes. Or have a mandatory retirement age. It was just another curious aspect of life in modern China.  

I couldn’t envision what it meant for a society to exist where a government somewhere could decree that all women would be forced to have a copper intrauterine device placed in their uterus upon having a baby, whether they liked it or not, and that it would remain in place indefinitely. It seemed even more preposterous that almost all the decisions said government made were made by men–the Chinese Communist Party is well known for being almost exclusively male at its highest levels. 

The actual IUCDs that the patients wear bear mentioning also. In North America, IUCD devices like the Copper-T, or Mirena, are little metal or plastic objects that are inserted into the uterus, with a trailing piece of string that dangles out of the uterus. The device itself prevents either ovulation or implantation of the embryo, depending on the IUCD in question. The little piece of string is designed to allow the device to be removed easily in a doctor’s office, where a doctor can tug on the string with a pair of forceps and remove the device. 

In China, the IUCD device is inserted without a string, making it deliberately more difficult for people to remove, even with proper medical equipment. 

As a result, many of my patients, after decades of wearing the IUCD, found that the device could not be easily removed. Canadian-trained gynaecologists, used to the simplicity of tugging on a piece of string and changing the IUCD every four or five years as per the manufacturer’s instructions, couldn’t always remove the Chinese IUCDs. Sometimes, it was because the Canadian-trained gynaecologists didn’t have the practice grabbing IUCD’s without the string. At other times, it was because the device had been put in place so long ago that it had shifted position and could no longer easily be removed. Some of my patients had to go under general anesthesia to have the device removed. Others got on airplanes and flew back to China to get the device removed there by the experts. All of this, I gradually realized, was part of the long-term consequences driven by China’s One-Child Policy. 

For a more detailed discussion of the One-Child Policy, see Barbara Demick’s Daughters of the Bamboo Grove. Demick, an L.A. Times journalist, chronicles her two-decade odyssey to help reunite an American-raised Chinese adoptee named Esther with her birth family in China. Esther was abducted as a two-year-old and then trafficked to an orphanage during China’s international adoption industry heyday in the early 1990s. As it turns out, she has a twin sister, Shuangjie, who stayed with her birth family and the story provides a fascinating case study of the entire issue of women’s reproductive rights and the issue of international adoption. 

In the book, Demick lays out China’s One-Child Policy and its ramifications on the grassroots level, where neighbourhoods were policed by local government family planning offices. These units were akin to local mafioso-like organizations, gangs of thugs who were given carte blanche by the local governments to cajole, threaten, and beat people into towing the party line. And, to top it off, they weren’t above kidnapping the children who violated the government’s restrictions on family planning. 

When it comes to the One-Child Policy, there is a tendency for us as Westerners to discuss it as tomfoolery–a straightforward story of failed macro-economic policy, that the One-Child Policy was short-sighted and hastened China’s likely imminent economic decline. And while this narrative may be accurate, it only scratches the surface. The reality of what happened to people on a personal level is much more complicated. 

As Demick describes it, in the nineties, the One-Child Policy essentially created the market conditions for international adoption and the trafficking of kidnapped children. It isn’t a huge leap of logic to understand that the One-Child Policy begets well-meaning people from the West wanting to adopt babies from China and being willing to pay good money to do so. Once money is involved, human traffickers realize that if they can get good money for babies, then all they need to do is to get more and more babies. Now, cue the kidnappings and forced baby abductions and we get to where we were. It’s a frightening cycle, which only illustrates yet again how economic policy can trickle down to the level of the individual in thousand-fold ways. 

There’s another aspect to Chinese family planning worth pointing out here, which is the desire to have more male children. The Chinese culture is by no means alone in this. Historically, many groups around the world prized boys over girls. In China, the reasons for this have long been established. Traditionally, Chinese culture has long placed an emphasis on families having male heirs. According to Chinese culture, family lineages pass through sons, and daughters are raised but then handed over to other families when they marry, unable to continue lineages of their own. At its most basic level, this meant that your son could look after you in your old age but your daughter couldn’t. 

Growing up as an immigrant in Canada, I accepted that the preference for boys over girls was probably one of those older, primitive world views that Chinese people held in the past, but, like binding women’s feet, surely not something anyone still believed in modern times. After all, I had grown up in a North America where women voted, moms were entering the work force en masse, and dual-income households were becoming more and more the norm. I took it for granted that modern people everywhere would value boys and girls equally. 

And while I had read in books about the gender imbalance in China, about how the One-Child Policy had created a nation with a surplus of boys over girls, I took it as just another example of primitive, traditional Chinese thinking, something from the old world, not something that I would have to deal with directly as a doctor in Canada. 

So imagine my surprise, when in my early years of practice, patients started approaching me, forcing me to confront some of these gender issues head on. 

One patient, an older woman who was already the mother of multiple girls, discovered that she was pregnant again. At the eighteen-to-twenty-week ultrasound, to her disappointment, she discovered that she was having a girl, again. A few weeks later, despondent, she came to my office, asking for a referral for an abortion. She explained to me that she wasn’t primitive or old-fashioned. Indeed, she wasn’t against having girls per say. But she already had so many that it seemed fair that she really didn’t want another one. 

By this point in the pregnancy, she was already precariously close to the twenty-four-week cutoff for late term abortions. In Canada, abortions past twenty-four weeks aren’t allowed. Would it be possible for me to change her estimated date of confinement to so that she could squeeze in just within the 24 week window?^⁠2 I refused to do this, and she ended up returning to the clinic multiple times in the next several weeks, each time suggesting that, telling us in fact, that she had remembered her last menstrual period date wrong. And that if we used her revised calculation, her current pregnancy actually fit in the twenty-four-week window. Needless to say, I did not acquiesce and eventually this patient drifted out of my practice. I never did find out what happened to her and her family of girls. 

Fortunately, not all the stories are so odd. Some patients from China have told me that they were pleasantly surprised to discover that in Canada, at the eighteen-week ultrasound, doctors could reveal the gender of their future children to them if they wished. Finally, they could prepare for the upcoming birth of their child knowing what colour to paint the child’s bedroom and what colour clothes to buy in advance. In China, I was told, this information was kept strictly confidential because the government was afraid that people would go looking for abortions if they found they were pregnant with a girl. 

Of course, now the situation in China is flipped. After decades of the One-Child Policy, China suddenly finds itself facing an economic slowdown, the prospect of an aging population and a more educated working class that wants no part of having more children. More and more young people in China are choosing not to even marry, not to mention start families. 

In a twist of dramatic irony, those same family planning units that harassed women for decades into having less children, have suddenly been tasked with the job of encouraging increased reproductive rates. 

What will the Chinese government do when it’s time to raise its low birth rate? What will it do when it realizes it can’t convince its citizens to get pregnant more readily by offering tax incentives? After all I’ve seen and experienced, it’s something I don’t even want to think about but could be just around the corner. 

I’ve long struggled to understand this concept of just how powerful the Chinese government is and how much impact it is able to have on its citizenry. Because my grandparents fled China after the Civil War in 1949 and my parents grew up in Taiwan under martial law, I’ve always had a bird’s-eye view of how Chinese politics can affect the lives of everyday people. I have an aunt who I’ve never met because she didn’t make it out of China in 1949 and became separated from our family–she wouldn’t see my father, her brother, for almost forty years. In recent years, I’ve read countless books about government reforms in China. I saw how China handled Covid-19 in the news. I’ve visited China and seen the gleaming new buildings and multi-lane superhighways humming with electric vehicles. But none of it has spoken to me as loudly as this collective shrug of indifference that I’ve encountered from my patients when it comes to women’s reproductive rights. 

Sometimes, I wonder what the psychic toll of a person doing something they don’t really want to do might be. What if they’re forced to get a tattoo that they don’t want? Or forced to cut their hair in a certain way? 

What if they’re forced into a marriage they don’t want? Or forced to have a baby they don’t want? Or forced to give the baby away against their will? 

They don’t even have the option of agreeing to any of these things. What if these actions are just done to them whether they like it or not? 

But then what about this: what is the psychic toll if they’re to wear an IUCD for the next thirty years, whether they would like to or not? 

What’s the toll if they’re given intravaginal misoprostol so that their baby can be born on an auspicious day? 

What’s the toll if they’re given intravaginal misoprostol so that an obstetrician can deliver the baby on a day convenient for him? 

If all of these decisions are simply made for a person by an aggressive husband, we’d call it abuse and everyone would be screaming bloody murder. But if these decisions are decreed by an even higher authority, an all-powerful political party or an all-seeing authoritarian government, then what? Would everyone just accept it as just another cultural fact of life, like using chopsticks instead of a fork? It seems like they would. 

To hear further discussion about Barbara Demick’s Daughters of the Bamboo Grove, have a listen to my discussion about it on Apollo On Call, the podcast of medhum.org. 

1. In Canada, health care is publicly funded but doctors can charge fees for services not covered by the public health care system. This can take the form of administrative fees as well as fees for certain medical and surgical procedures that the government health insurance doesn’t cover. 
2. The estimated date of confinement is the projected due date for a pregnant mother. It can be calculated as 40 weeks from the date of the pregnant woman’s last menstrual period, or estimated using prenatal ultrasounds. 

Web Image by Medhum.org and Fred Moon 

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 798

From Tigers to Otaku

09.16.25 1675

The Happiest Couple

07.28.25 1416

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 1994

A few years ago, a patient of mine, a young man, was diagnosed with bipolar disorder. In the middle of university, his grades suddenly nosedived, and he was found talking incoherently by his roommates, who called the police.

Not long thereafter, his mother, distraught, came to see me in the office. She told me the story of their lives. How she had struggled to raise him on her own in North America while her husband lived overseas and how she had pushed them to attend a renowned public school in the area. Now she wondered if she was to blame for the whole thing. Had she done something wrong? Had she pushed them too hard? Was this all her fault?

I’ve been practising as a family physician for Chinese Canadian immigrant patients for almost two decades, and my practice runs the gamut from newborns a few days old right on through to adulthood. Not only that, I grew up as a second generation Chinese Canadian immigrant, the son of two Chinese immigrants from Taiwan. And now I’m a parent myself, raising the third generation of Chinese Canadian immigrants. After all this, I feel like I should know a thing or two about Chinese immigrant parenting but the truth isn’t so simple. It’s probably closer to truth to say that Chinese immigrant parenting is something that I have lived through and have many strange and conflicted feelings about.

There is definitely a playbook that Chinese Canadian immigrant parents subscribe to. The playbook is an extension of the Chinese immigrant workhorse mentality. When you come to a country with nothing but hope and work ethic, you somehow create an ethos built around filial piety, discipline, and a strong sense of duty. This parenting model, tried, tested and true, reads something like this:

• A heavy emphasis on academics and education, with emphasis placed especially on mathematics and sciences.
• A high level of parental expectations.
• Combining the above two points creates the expectation that when it comes to your academics, you will outwork your lazy, North American counterparts
• A carefully curated collection of after school activities, always including some attempt at playing a classical music instrument. Even here, you will outwork your lazy, North American counterparts.
• Going to university. Once in university, you will once again, outwork your lazy, North American counterparts.
• Landing a well-paying job, preferably as a professional in the big three (doctor, lawyer, engineer). If not, then business. In all these fields, you will, once again, outwork your lazy, North American counterparts.

The playbook may sound draconian, but in many ways, it works. Asian immigrant children are known for succeeding academically. They make it into top university programs in large numbers, so much so that some people were worried that certain elite schools were starting to modify admission criteria to decrease Asian students’ enrollment.

Asian Americans disproportionately land jobs in medicine, law and engineering and as adults, do disproportionately well financially. All of this conveniently fits into the model minority myth. The myth says that all Asians are hardworking and reliable. They do well in school, they don’t complain, and they work hard in their upwardly mobile careers.

This heavy-handed approach to parenting gained parlance in popular culture with the publication of Amy Chua’s infamous memoir, “the Battle Hymn of the Tiger Mother.”

Published In 2011, the book was described as a parenting memoir by Yale Law professor Amy Chua and became an international best-seller. In the book, Chua described her parenting journey, as she demanded, insisted, and pushed her children to academic and musical success. Her older daughter ends up performing at Carnegie Hall and eventually, in the years after the book was published, both daughters graduated from Harvard University.

I read the book a few years after it was published. From all the press clippings and popular discourse about the book, I had expected that the book to present a bullet proof justification for tiger parenting.  And indeed, the mother in the book was certainly recognizable to me. She was an amalgam of many of the Chinese immigrant parents I had known growing up, including some aspects of my own.

The book does in fact, describe many classic tropes of the typical Asian American parenting regimen. The disproportionate emphasis placed on learning classical music instruments, the high strung, pushy helicopter parent, the unrelenting expectation of academic success. Chua described booking family vacations only at hotels where a piano was available to be rented.

But what I did not expect was that this was only the setup of the book. In the second half of the book, Chua’s defiant younger daughter, Lulu, decides enough is enough and refuses to give in to her mother’s insistence on playing the violin. In time, she reduces her violin practice time to a measly thirty minutes a day and takes up that most un-Asian of pursuits, sports in the form of competitive tennis, and Chua concludes that the best form of parenting is neither something entirely tiger, but something in the middle, a cross between east and west.

In a culture where few people read but everyone likes to give an opinion, the book’s denouement was lost on most people. Amy Chua and the term “tiger mother” became an avatar for all the aspects of Asian American parenting that were deplorable, but few people chose to remember Chua’s tongue in cheek look at her own parenting.

Instead, the reaction of most westerners to the “tiger mother” phenomenon was one of disbelief, something along the lines of “those crazy Asian parents and their crazy parenting ideas.” But what I found most interesting was Asian people’s response to Chua’s book. Most Asian parents did not see Chua’s style of parenting as harmful or strange. Extreme, maybe, but in principle, no different from any other Asians. In my family, my cousins and I read the book and decided that our parents weren’t really tiger enough. Yes, we had been forced to play the piano and the violin. But not for six hours. Six hours! Can you believe it? Now that is crazy.

As much as I’d like to be critical of Asian American parenting, I must say that in my time with my Chinese Canadian patients, I’ve seen plenty of success stories.

I’ve had patients who find time to play both the piano and the violin while commuting an hour each day to the most elite merit based private schools in the city.

I’ve seen children who are being shuttled between all manner of competitive swimming, gymnastics and ice hockey lessons. Often, just hearing these children’s schedules is enough to make me dizzy but the families somehow make it work.

Sometimes, I’m tempted to ask the parents if it’s possible that they could just let their foot off the pedal and let their kids be kids. That’s the western upbringing in me coming out. But then I remember how in elementary school, one day my teacher asked us to tell the class what after school activities each of us was involved in. This was the late eighties, when over-parenting wasn’t really a thing yet, and I remember how my classmates howled with laughter as I rattled off all the strange extra-curricular activities my parents would be toting me to that summer: piano lessons, swimming lessons, tennis lessons, Chinese school and a cooking class. Most of my classmates were lucky to have one activity to do. I had five. At the time, I laughed along with them, finding the whole thing funny. But now, decades later, when it comes to parenting, I wonder who really gets the last laugh.

At the opposite end of the achievement spectrum, is the Otaku child. The term Otaku is Japanese and was initially a reference to Japanese youths who were obsessed with computers and popular culture. The classic example was the nerdy Japanese boy, imbibing huge quantities of Japanese anime and manga while sitting in their rooms playing video games all day. This was a mostly Asian phenomenon, rarely talked about in the west.^⁠1  In the last several years though, especially since the COVID pandemic, I’ve watched as a growing number of my adolescent patients stopped attending school. I’d find out about these cases from exasperated parents, who would come to the office, often alone but sometimes accompanied by their taciturn child, seeking out a medical solution for what was going on.  

The cases had some similar themes, though none was exactly the same as the others. In most of the cases, the child did not have a strong relationship with their parents. Often they had retreated into an online world on the internet. Sometimes, online gaming was involved, but sometimes the children insisted they just surfed the internet, watching videos or engaging with social media.

Generally speaking, the children weren’t terrible students in the traditional sense of children who were really struggling academically. They were mostly strong students. Several of them were even identified as gifted.

Poor sleep habits were often an issue for these children. They’d often be on their computers into the wee hours of the morning, and then unable to wake up for class, if they bothered to attend at all. Eventually, they’d stop attending classes altogether.

The children tended to spend much of their time in their rooms, rarely interacting with the household, often not joining their families even for meals. As the frustration of the parents grew, so too would the hostilities in the household. The parents would try to break the internet addiction by withholding computer hardware or turning off the WIFI. Such escalations would be met with confrontations, leading to overturned television sets or even suicidal gestures.

The ages of the children varied. Some were as old as high school. But some were as young as middle school.

In all cases, the commonality was that the parents were stuck. They didn’t know how to proceed. And as their family physician, I didn’t know either.

When I went to medical school, school absence was not a medical diagnosis. Neither was video game addiction. But the medical and psychiatric world I was trained in did not have cell phones or social media or Facebook or TikTok. What it had was a few narrow definitions for similar behaviours: conduct disorder, oppositional defiant disorder, and substance abuse disorders. The children in these school avoidance cases fit some of these definitions, but never wholly.

I’ve watched as parents tried everything they could to find a solution for this issue within a medical system that doesn’t really know what to do with these cases. Beleaguered parents bringing their children to see me is only the first step. I’ve sent these patients to see psychiatrists and psychotherapists and paediatricians with mixed results. There isn’t much these specialists can do with an uncommunicative child who doesn’t want to be there. I’ve seen patients call the justice of the peace to issue a community treatment order so that their own child gets ordered by the courts to go to a hospital for an assessment by a psychiatrist. I’ve seen patients drag their child to the emergency room for school absence and read consult notes by well-meaning ER doctors who try their best to persuade the child to resume going to school. I’ve even been called by well-intentioned police officers, who want me to do something about the child they’ve just been dealing with, because they have no idea what they should be doing either.

Of course, school absence isn’t something that’s new or wholly unique to Chinese immigrants. I still remember my first week of high school back in 1992, watching as a classmate of mine was dropped off by his mother at the front door, and as soon as the car disappeared down the road, he turned around and headed away from the school building.

But that was high school and for whatever reason, in those days, we never thought of those kids as being “medical cases.” If you wanted to blow off classes and spend your day smoking cigarettes just off the school grounds, that was your choice. It wasn’t something you dragged your children to see a doctor about.

In fact, the “high-school dropout” has always been a known character trope, around for probably as long as organized education has existed. But there’s something especially jarring when seeing these cases of high school dropouts play out against the backdrop of tiger parenting and the model minority myth. And there’s something even more visceral to it when the issue starts to appear in middle school aged children.

I wish I could say that all of these stories of school avoidance end well. Some of them do: after a few years of feuding with their parents, the child grows up, and some go back to school. But for others, the jury is still out. I’m still waiting to see what happens.

So what does it all mean? How can well-intentioned Chinese Canadian immigrant parenting, produce such a broad spectrum of results? Super successful overachievers on the one hand, and Otaku adolescents who refuse to leave their rooms and are on suicide watch on the other?

I don’t have an answer, except to say that both of these groups of children are products of the same parenting paradigm. And just like when my patients ask me if they are to blame for their children’s mental illness, there is no real answer. There’s no way to definitively connect a line between the Asian parenting model and the types of children it produces.

But just as we can draw a line between pushy, tiger parenting and academic success, we probably can also draw a similar line between pushy, tiger parenting and Otaku children and social withdrawal. It’s easy for the Asian parenting model to claim its successes, but it’s time for the Asian parenting model to also accept some of the damage it has wrought onto its children.

Ultimately, most of my paediatric patients go through to university. The majority are in the typical model minority fields: engineering, computers, medical school and law school. 

But occasionally I’ll meet one who is studying something a bit more off the beaten path: fashion, or design, or cinema or something like that. They may be taking degrees in those programs, or they’ve pivoted after university and are making their way far off the traditional, beaten path. I’ll look at them, I’ll know that in some small way, they’ve broken out of the paradigm. I know they’re putting their parents through agony, but for what it’s worth, I’m proud of them.

1. I remember a lecture in medical school talking about the cultural basis of diseases. Certain diseases were common in the West but almost unheard of in Asia-the example of eating disorders was given. For the opposite example of diseases common in the East but rare in the West, the example given was the Japanese Otaku child.
Web image created by Medhum.org

Photo of the Hsu family in the 80s provided by Dave

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 798

From Tigers to Otaku

09.16.25 1675

The Happiest Couple

07.28.25 1416

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 1994

One Patient, Two Systems 

02.24.25 2679

The artist depicts Chekhov as he was in the early 1890’s, soon after he had purchased a small, dilapidated estate and moved there from Moscow with his family. In addition to serving as country doctor and public health official in Melikhovo, Chekhov at that time was composing many of the stories and plays that made him one of Russia’s most well-loved writers and a major influence on 20^th century literature. How was he able to pursue two such different and demanding careers? Several years earlier, at the height of Chekhov’s early literary success, his friend Alexi Suvorin had urged the young writer to give up medicine. Don’t spread yourself too thin, he said. You’ll never reach your potential unless you concentrate on writing. In response, Chekhov wrote, “You advise me not to chase after two hares at once and to forget about practicing medicine. Well, I don’t see what’s so impossible about chasing two hares at once… Medicine is my lawful wedded wife and literature my mistress. When one gets on my nerves, I spend the night with the other. This may be somewhat disorganized, but then again, it’s not boring, and anyway, neither loses anything by my duplicity.” (1) In this famous passage, the 28-year-old writer dances lightly over a fundamental truth of his life and identity. In fact, Chekhov’s career was not so much a matter of jumping from one bedroom to another, as was the case perhaps with the poets Wallace Stevens and T. S. Eliot, or the composer Charles Ives. Rather, Chekhov thrived on the effective, if not always seamless, integration of the arts of medicine and writing, which reinforced one another throughout his creative life. This essay explores that integration, and the manner in which Chekhov’s cold eye (objectivity) and warm heart (compassion) reveal themselves in his medical and literary lives. 

DOCTOR CHEKHOV  

“Medicine Is My Lawful Wife” 

When he graduated from the Moscow State University School of Medicine in June 1884, Chekhov was already earning his living as a professional writer. The grandson of serfs, Anton was the third of six children in a poor merchant family from Taganrog, a southern provincial town on the shore of Sea of Azov. His father had moved the family to Moscow after going bankrupt in 1877. By the time Anton entered medical school on a scholarship in 1879, the Chekhovs were living in squalor. His father had a dead-end job. His older brothers were alcoholics and generally unemployed. Anton soon discovered that he could ameliorate the situation by selling comic sketches to local magazines for eight kopecks per line. This was a type of moonlighting he loved. He wrote obsessively, often knocking off a story or two each night, after spending the day listening to lectures or working in the hospital. Chekhov ultimately published more than 200 pieces while a medical student, most of them under his preferred pseudonym, Antosha Chekhonte. 

Chekhov was a natural storyteller. Thus, it wasn’t surprising that the newly minted Doctor Chekhov continued to write, even after he opened his office and patients began to arrive. “Continued to write” is an understatement. Chekhov published 54 stories in 1885, 76 in 1886, and 57 in 1887. His work evolved from humorous sketches to longer, more serious stories for leading literary journals. In 1888 Chekhov won the prestigious Pushkin Prize and published “The Steppe,” his longest and most innovative story to date. Ivanov, his first full-length play, had a successful premiere in St. Petersburg in January 1889. By that time the young doctor had become one of the best known writers in Russia. 

Yet Chekhov always saw himself as a physician, even though in 1889 he did, in fact, retire from a normal paying practice; after that, he offered his medical services at no charge, even though the generous Chekhov often found himself financially strapped. He took care of the peasants near Melikhovo (as depicted in the painting), donated his services to the government as a district physician, and engaged regularly in public health initiatives. In less than five months in 1891, Chekhov reported seeing 453 patients at a district health center and making 576 house calls, in addition to his home practice. (2) Throughout his life, Chekhov also was heavily involved in grass roots activism, building schools for peasants, raising funds to help famine victims, and, later, near the end of his life, supporting the establishment of a sanitarium for tuberculosis victims at Yalta.  

“My Debt To Medicine” 

One of the best known of these public health efforts was his 1890 epidemiological survey of health and social conditions in the prison colonies on Sakhalin Island. Traveling by himself, Chekhov journeyed six weeks by train, steamboat, and horse-drawn carriage across Siberia to reach the 1000-km long Pacific island on which the Czarist government had recently established a notorious gulag. There, he embarked on a one-man, three-month survey of the population, tenaciously picking his way from settlement to settlement and from house to house, often by foot.  

Biographers have long tried to pinpoint his motivation for this perilous journey. During the year prior to the trip, Chekhov had undergone a crisis of confidence. In a letter to Suvorin, he opined, “I don’t love money enough for medicine, and I lack the necessary passion—and therefore talent—for literature. The fire in me burns with an even, lethargic flame; it never flares up or roars… I have very little passion. Add to that the following psychopathic trait: for two years now, seeing my works in print has for some reason given me no pleasure.” (3) He reported symptoms suggestive of clinical depression, perhaps precipitated by grief over the death of his brother Nicholas from tuberculosis. There was also a literary issue. The master of the short story had promised himself that he would create a Tolstoy-like novel that would confirm his status as a serious writer. But he was unable to do so.  

Undoubtedly a major factor for choosing Sakhalin was Chekhov’s desire to pay his debt to medicine. He had recently developed a scientific interest in penology and had read about the dismal conditions in the Siberian gulag. He saw an opportunity to influence this situation by obtaining accurate data on the health status of Sakhalin convicts. He had never completed the research thesis (the equivalent of a Ph.D.) that would make him eligible to be a medical specialist or professor. Hence, his notion of “my debt to medicine”—he would perform a survey, write his thesis, and become a teacher. 

Ultimately, Chekhov claimed to visit every settlement and survey every household on Sakhalin Island, using a 12-item data collection form. He said he completed over 10,000 of these forms in three months, a feat that (if true) qualifies Chekhov as the speediest shoe-leather epidemiologist of all time. After his return to European Russia, the author found it difficult to organize his data into a coherent study. While he had planned to write a strictly scientific monograph, his creative spirit struggled with the limitations of science. What about his personal experience? What about the interesting stories? After struggling for years, in 1895 Chekhov published The Island of Sakhalin, a curious (but engrossing) mixture of journal, geography, history, medicine, statistics, and travelogue. (4) Unfortunately, the faculty of the University of Moscow was unimpressed.  

“As I Grow Older, the Pulse of Life in Me Beats Faster” 

Picture the mature Chekhov—a middle-aged bachelor, longish face, rather neatly trimmed beard, a prince-nez clipped to the bridge of his nose. His household included his aging parents and his sister Masha, an unmarried schoolteacher who had become his confidant and secretary. His three surviving brothers looked to him for guidance and financial help. Anton was popular, witty, and generous. Among the guests at Melikhovo, there were frequently female admirers. Chekhov’s encounters with women were flirtatious and obviously enjoyable. He had teasing, sexually charged relationships with several women, but whether any of these liaisons are actually “affairs” is uncertain.  

The doctor in the painting already suffered from the tuberculosis from which he would die at the age of 44 years. In fact, he first coughed blood as a medical student. Yet, Chekhov dismissed that episode and each subsequent episode that occurred with disheartening regularity as “influenza” or “bronchitis,” steadfastly refusing to label himself consumptive. As a physician Chekhov must surely have understood the meaning of his symptoms. Was his denial simply a face to show others? Or was his denial so great that it made him unaware? The cat finally came out of the bag in early 1897. While dining at a restaurant in Moscow, Chekhov had a violent spell of hemoptysis that left him critically ill. For the first time, he sought medical treatment and entered the clinic run by Dr. Ostropov, one of his medical school professors. Chekhov’s chronic illness progressively worsened. At the insistence of his doctors, Chekhov left his beloved Melikhovo after 1898 and lived mostly at a new home in the sunny Black Sea resort of Yalta. 

It was also during these last years that the bachelor writer courted and married Olga Knipper, an actress with the Moscow Theater Arts Company. Even after their marriage in 1901, Olga remained at work in Moscow during much of the year, while the invalid Chekhov lived in Yalta, theirs being perhaps one of the earliest examples of the modern two-career commuter marriage. Chekhov found himself able to devote less and less of his waning energy to writing, especially since he refused to give up his social and philanthropic activities. Nonetheless, between 1898 and his death in 1904 Chekhov completed some of his greatest work, including several stories, two novellas (“Peasants” and “In the Ravine”), and his last plays, The Three Sisters (1900) and The Cherry Orchard (1903).  

COLD EYE, WARM HEART 

Chekhov’s Doctors 

Several characteristics of Chekhov’s work reveal the influence of medical training and practice. He used clinical knowledge to lend accuracy to his descriptions of disease and medical situations. This characteristic is perhaps most clearly seen in the characterization of mental disorders. For example, the title character in Ivanov is a subtle portrait of a man suffering from clinical depression, who eventually commits suicide. The young heiress in “A Doctor’s Visit” presents symptoms we would now label as generalized anxiety or panic disorder. The title character in Uncle Vanya appears to have a neurotic depression, a condition that meets today’s DSM 5 criteria for Persistent Depressive Disorder. In the peculiar story called “The Black Monk,” Chekhov describes a psychotic condition, presumably schizophrenia.  

Chekhov also drew from his medical experience in creating a multitude of physician characters. Doctors play significant roles in nearly 30 stories and in all of his major plays, except The Cherry Orchard. The author’s sensibility as a medical insider gives insight and poignancy to these characters, who range from committed altruists to lazy bureaucrats to burned out cases. Chekhov knew too much about the contemporary state of medical science to portray his doctors as curing many people. Thus, they often appear impotent. Yet, at their best Chekhov’s doctors convey the seamless fabric of tenderness (compassion) and steadiness (detachment) that lies at the heart of good medical practice. They also demonstrate courage, altruism, and self-effacement. For example, in “The Grasshopper” (1892) Dr. Dymov dies as a result of contracting diphtheria from a patient. Dr. Kirilov in “Enemies” (1887) demonstrates extraordinary devotion to duty by leaving his distraught wife and dead son in order to make an emergency house call.  

Perhaps Chekhov’s most textured portrait of a good physician appears in “A Doctor’s Visit” (1898). The protagonist, Korolyov, is a young doctor substituting for his boss, the professor of medicine. During the course of the story he moves from being a careful observer (detached concern) who ascertains that his young patient has nothing wrong but a “case of nerves,” to making an imaginative leap by which he connects more deeply with her. This empathic connection allows him to relieve some of her suffering by re-framing her illness. While he cannot solve her existential problems, his demonstration of solidarity leads her to trust him and to gain insight. Korolyov is like Chekhov himself. Dr. Pavel Archangelsky, who supervised Chekhov’s first job as a physician, captured the author’s ability to listen carefully when he later commented: “… he did everything with attention and a manifest love of what he was doing, especially toward the patients who passed through his hands. He listened quietly to them, never raising his voice, however tired he was and even if the patient was talking about things quite irrelevant to his illness.” (5)  

At the other end of the spectrum, some of Chekhov’s doctors are insensitive, incompetent, or impaired. Mayer, the callous medical student in “A Nervous Breakdown” (1889) is a disaster. Mayer can rattle off statistics on the number of whores in London and Moscow, but he is unable to “see” (empathize with) the suffering of the living-and-breathing whores he encounters. Shelestov in “Intrigues” (1883) and the public health doctor in “Darkness” (1887) are examples of self-centered physicians a little further along in their professional lives. The former is superficial and pompous; the latter is narrow-minded and detached.  

Chekhov’s most complete insensitive and acquisitive social climber is found in “Ionych” (1898). Dr. Startsev, when the reader first meets him, is a young physician setting up practice in a provincial town. After surviving an unrequited infatuation with the daughter of a wealthy townsman, Startsev devotes himself entirely to work. His practice prospers and he branches out into real estate. As he grows corpulent and wealthy, Startsev loses touch with his patients (and his own humanity): 

“Probably because his throat is covered with rolls of fat, his voice has changed; it has become thin and sharp. His temper has changed, too; he has become ill humored and irritable. When he sees his patients, he is usually out of temper; he impatiently taps the floor with his stick, and shouts in his disagreeable voice: ‘Be so good as to confine yourself to answering my questions! Don’t talk so much!’” (6) 

“Ionych” traces the progressive destruction of a medical practitioner who finds that medical affluence is more to his liking than the emotionally and physically difficult path of medical virtue.  

Some of Chekhov’s most interesting doctors are tortured by existential or spiritual conflict. Chekhov accurately depicted professional burnout, a syndrome characterized by depletion, detachment, depersonalization, denial, and depression. (7) Dr. Kirilov, who chooses to “go to the office” instead of mourning with his wife, may illustrate the relatively early phase of emotional detachment. Dr. Ovchinnikov in “An Awkward Business” (1888) demonstrates the more advanced symptom of depersonalization when he slugs his assistant in response to the man’s incompetence. The overworked Ovchinnikov reacts to his personal depletion by objectifying and dehumanizing his assistant, a response that compromises the medical care he is trying to protect. Chebutykin in The Three Sisters (1900) illustrates the extreme of alcoholism. Though still employed as a military physician, Chebutykin convincingly asserts that he has forgotten all the medicine he ever learned.   

Ragin in “Ward #6” (1892) and Nikolai Stepanovich in “A Dreary Story” (1889) are complex characters in whom depression and burnout are superimposed on a deep sense of existential failure. Like many of Chekhov’s characters, these physicians suffer from a lack of self-knowledge; they move through life relying on one form of self-deception or another. When they were younger, they committed themselves to noble ideals—Stepanovich to teaching and Ragin to practice in a provincial hospital. But in the long run they never “found” themselves. Professor Stepanovich yearns for a unifying moral principle that would knit together the fragments of his life. Dr. Ragin experiences his failure as emotional numbness. He yearns to suffer, assuming that if he experienced pain, he would be freed from his inability to feel. Thus, the academic physician pines for salvation in the cognitive sphere; the practitioner yearns for emotional redemption. In each case the focus remains inward, rather than turning outward to others, in whom salvation might actually be found.  

Medical Sensibility 

Medical attitudes and methodology play a larger role in Chekhov’s work than does medical knowledge. He believed that his duty as a writer was to present his observations clearly and accurately; in other words, to lay out the data in an objective fashion and allow readers to reach their own conclusions, rather than providing an author’s interpretation. He wrote, “The artist should not be a judge of his characters and what they say, but only an objective observer.” (8) 

This objective attitude put him in conflict with most other Russian writers of the time. It was a major source of conflict with Tolstoy, who was widely revered at the time as a living saint. The two men enjoyed a close personal bond but approached writing with radically different philosophies. After his mid-life religious conversion, Tolstoy viewed literature as a way to communicate his moral vision. He preached the gospel of a radical Christianity, in which all men work together to achieve economic and social equality. However, he rejected the concept of material progress and was particularly skeptical of medicine and doctors. Chekhov, on the other hand, strove to be objective, to present people as they are and the world as it is. His medical training taught him to be a careful observer; his medical attitude made him leery of judging others.  

Other Russian writers and intellectuals spoke out against the czarist government’s repressive social institutions. While this protest was disguised in various ways in order to satisfy the state censors, late 19^th century Russians (like their 20^th century counterparts) learned to speak and understand a subtle code of insurrection. The intellectuals addressed “big issues”—democracy, education, social revolution. They wrote articles, organized meetings, and gave speeches. Here again, Chekhov found himself on a different wavelength. He rarely engaged in theoretical discussion and did not advocate radical social change. Rather, he preferred a pragmatic, case-based approach. His goals were relatively limited, but achievable. Treat the sick patient. Document and publicize the abysmal condition of prisoners. Contain the cholera epidemic. Provide financial assistance to keep farmers afloat during the famine. Raise money for a new school. On and on, but always specific and personal.  

In “About Love” (1898), the narrator speculates on the essence of love. Are there universal characteristics that identify love wherever it occurs? “What seems to fit one instance doesn’t fit a dozen others,” the narrator concludes. “It’s best to interpret each instance separately in my view, without trying to generalize. We must isolate each individual case, as doctors say.” (9) Indeed, Chekhov’s stories and plays rigorously follow this dictum. While many of his Russian contemporaries used fiction to advance moral or social theories, Dr. Chekhov focused on the complexities of human interaction. In Chekhov’s world, biology and circumstance constrain freedom. People often do not listen. Acts performed with good intentions frequently result in hurtful outcomes. And yet occasionally and in unexpected places, one finds a glimmer of love, courage, spirituality, or healing. “Never generalize,” Chekhov tells his readers. “Never theorize. Pay attention to the particulars. Focus on the concrete.” In this respect, the 19^th century physician-storyteller presages the 20^th century physician-poet, William Carlos Williams, who coined the aphorism, “No ideas but in things.”  

In the long run, Chekhov’s objectivity and aversion to theory played a major role in the development of modern literature, as 20^th century writers followed Chekhov in attempting to describe the world of human character and relationship objectively, and allowing that world to speak for itself. To the extent that Chekhov’s “lawful wedded wife” contributed to his sensitivity, skills, and attitudes, perhaps medical education and practice played an unanticipated role in the history of literature, his delightful “mistress.” 

Adapted in part from Coulehan J. (Ed.) Chekhov’s Doctors, Kent State University Press,  2003

Sir Luke Fildes’ “The Doctor,” is in the Tate: File:The Doctor Luke Fildes crop.jpg – Wikimedia Commons 

Portrait of Chekhov: File: Chekhov 1898 by Osip Braz.jpg – Wikimedia Commons 

REFERENCES 
1, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p.  
2, Coope J. Doctor Chekhov. A Study in Literature and Medicine, Chale, Isle of Wight, Cross Publishing, 1997, p.  
3, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p. 81. 
4, Chekhov A. A Journey to Sakhalin, translated by Brian Reeve, Cambridge, Ian Faulkner Publishing, 1993.  
5, Coope J. Doctor Chekhov. A Study in Literature and Medicine, Chale, Isle of Wight, Cross Publishing, 1997, p. 27. 
6, Chekhov A. Ionych. In: The Tales of Chekhov. Volume 3, translated by Constance Garnett, New York, The Ecco Press, 1972, p. 91. 
7, Coulehan JL. Being a Physician. In: Mengel MB, Holleman WL (Eds.) Fundamentals of Clinical Practice. A Textbook on the Patient, Doctor, and Society, New York, Plenum Medical Books Company, 1997, pp. 73-101. 
8, Chekhov A. The Selected Letters of Anton Chekhov, translated by Sidonie Lederer, New York, The Ecco Press, 1984, p. 54. 
9, Chekhov A. About love. In: The Tales of Chekhov. Volume 5, translated by Constance Garnett, New York, The Ecco Press, 1972, p. 290.

Reviews of Chekhov’s Stories

Cold Eye, Warm Heart: Medicine and Anton Chekhov  

Aug 6, 2025 6275

An Awkward Business by Anton Chekhov 

Jun 11, 2025 1423

The Grasshopper by Anton Chekhov

May 11, 2025 1242

Ionych by Anton Chekhov 

Mar 11, 2025 2055

A Doctor’s Visit  by Anton Chekhov 

Mar 11, 2025 1722

Ward No. 6 by Anton Chekhov

Mar 11, 2025 3232

A Nervous Breakdown by Anton Chekhov 

Feb 11, 2025 1463

Enemies by Anton Chekhov

Jan 11, 2025 1557

Painting an Ideal: Luke Fildes’ The Doctor with Hannah Darvin

Dec 28, 2024 1220

After eighteen years of clinical practice, I think I’ve looked after somewhere between four and five thousand patients in total. Some patients I meet only a handful of times. Others I know like extended family. There are all types of patients: pleasant ones, well-behaved ones, as well as difficult ones that try my patience and of course, some that I’d rather forget.

Of course, most of my patients are Chinese immigrants and immigrating is a difficult business, not something to be undertaken by the faint of heart. New home. Often a new language. Usually a whole new culture. The immigrant experience means uprooting a person or a family from all that they are comfortable with and placing them in a strange and unfamiliar setting.

If being an immigrant is hard, then being an immigrant as a senior citizen is even harder. Try learning English for the first time when you’re in your sixties and seventies. Try going to the bank or dealing with a leaky faucet when you are a stranger in a foreign land. And yet, I’ve seen countless examples over the years of Chinese seniors starting over in Canada somewhere in their sixth or seventh decades. I often wonder. What is it that makes them want to start over yet again in their life? Is it simply that they want to be closer to their children and grandchildren who’ve come to Canada? Is there nobody left back in their home country? Do they really know what they are in for? Can anyone really be prepared for it?

In my own family, I’ve seen this process of elderly immigrants play out firsthand. Both of my grandmothers spent portions of their later years living with my parents in Toronto, with varying degrees of success. Through them, I witnessed just how difficult it could be to be an elderly Chinese immigrant in Toronto, which is probably, with its enormous Chinese population, already one of the most Chinese-friendly cities in the world outside of Asia. 

In Taipei, my grandmothers could walk outside in the mornings and bring back fresh produce and noodles from the market down the street in their respective neighborhoods. Never mind that the produce in the Food City and Miracle Food Mart of my childhood was nowhere near as a fresh or tasty as the food culled on the subtropical island of Taiwan: in Toronto, our family lived in the suburbs of Scarborough, and later North York, so my grandmothers could only visit a store if my father was free on the weekends to drive them.

Of course, my grandmothers couldn’t read or speak much English. In the era before cellular phones and Google maps, my parents taught them to navigate the Toronto subway system by memorizing the pattern of the coloured tiles at the individual subway stations, back when the city made a point of individualizing each station’s appearance. Dundas Station meant yellow coloured tiles. This was important because this way my grandmother knew which spot to get off if she wanted to find Chinatown.

My maternal grandmother abhorred Canada. Her complaints were plentiful: the produce didn’t taste fresh, the winter weather was too cold, it was too difficult to go places without a car and the language barrier was insurmountable. Ultimately, nothing about life here was as easy or as convenient for her as life in Taipei. At some point, she actually learned enough English to pass her Canadian citizenship exam. But years later, she defiantly informed me that she had returned all that knowledge back to her teachers. She had forgotten it all.

My paternal grandmother didn’t voice her complaints about Canada as much. Whether it was because she was more content, or simply because she tended to keep more to herself, I’m not sure what she ultimately thought about being a Chinese immigrant. But watching from afar as she spent the long months from spring to fall in our house (she always returned to Taiwan before it got too cold), living with my mom while my father was mostly out of the house, I couldn’t help but surmise that things weren’t really that easy. She didn’t learn much English, and save for her morning walk around the neighbourhood, she rarely ventured outside the house, preferring instead to spend most of her days watching satellite television from Taiwan. Living with grandchildren you don’t know very well, a son who is usually at work, and making nice with your daughter-in-law on a regular basis; this was another form of the Chinese Canadian immigrant experience.

This phenomenon, that of the frustrated elderly immigrant, is one that I’ve seen countless times in my medical practice. Flummoxed by a language they don’t understand, struggling to live under the roof of a son or daughter-in-law that they aren’t completely in sync with, and often tasked with the thankless job of babysitting little grandchildren for no pay, the immigrant elderly experience is fraught with trials and tribulations. And that is before real crises hit the family: a car accident, or a health situation, or worse. Crises are difficult enough when you are surrounded by your social safety net of familiar family and friends. But now, imagine being in an unfamiliar country when life unloads a crisis as it is wont to do. The examples are endless, but the end result is the same. Frustration, resentment, and ultimately regret. Why did we ever bother to come here?

Over the years, I’ve seen versions of it all. Disinterested adult children chauffeuring their elderly parents to doctor appointments, and those children then falling asleep in the chairs while their parents are describing their symptoms next to them. Other times, I’ve seen seniors get chastised verbally by their children when they try to ask me one question too many. I’ve treated elderly patients who got into physical altercations with their son-in-laws. And it goes both ways too: I’ve seen adult children come to me to request Prozac knowing that their mother-in-law will be arriving a month from now.

When I sat down to write this piece about elderly immigrants, I thought about which of my patients I really wanted to know more about. One couple, the Chens, immediately leapt into my mind. I’ve changed their names here to protect their privacy. 

On the surface, there’s nothing special about them. They’re an elderly Chinese couple, living in Toronto while their children live elsewhere. They aren’t particularly well off, and they spend their retirement doing typical Chinese immigrant senior citizen things: attending doctor visits, taking classes at the community centre, and so forth.

But dig past the surface, and they are unique. They’ve been married for over sixty years, and they are quite possibly the happiest, most resilient seniors I know. When things happen to them that would certainly derail others, they laugh about it, avoid blaming others and then move on. I’ve seen it happen in my office many times.

A few years back, Mr. Chen was struck by a car while crossing the street as a pedestrian, injuring his shoulder. For many patients, this would be a cue for initiating legal proceedings and a demand for compensation, as well as an endless stream of doctor visits and requests for pain medications. How did Mr. Chen handle it? He laughed it off, dismissed my question about “who was at fault” in the accident and recovered within a few months while doing some exercises with a physiotherapist.

Not too long after that, Mrs. Chen was found to have a slowly growing brain tumour. For many patients, this would be cause for anxiety, angst and even hysteria. But for Mrs. Chen, it was just another fact of life. She decided that in her mid-eighties, she didn’t need to risk surgery, and she’d continue to live day by day, even though the neurosurgeons thought that a more aggressive approach might improve her mortality and her quality of life, especially if her vision were to decline further. But they didn’t take into account that she was already fine with her quality of life and didn’t see the need to potentially upend things with surgical complications. Now, three years later, she’s remained the same, happy, laughing patient, who always makes a point to end our visits with a “good bye“ or ”thank you very much,” spoken in English that she learned in her English as a Second Language class.

Actually, I’ll correct what I said earlier. The Chens aren’t just the happiest seniors I know. They are quite possibly the happiest, most well-balanced people I know. What is the secret sauce of their happiness? That’s what I set out to find out. And that’s what I explained to them when I brought them into my office to be interviewed a few weeks ago.

This is their story.

The first thing to point out is that neither Mr. nor Mrs. Chen’s life was easy. If we suspected that part of the magic sauce of resilience is the ability to live a peacefully blissful existence in a Garden of Eden type environment, the Chens’ lives, dating back to their childhood, shows that this is not the case.

Mr. Chen was born in a small town in the province of Shanxi, in Northern China in 1937. At that time, China was at war, trying to stave off Japanese occupation, and so he grew up in an environment where war and violence were everywhere. In fact, the Japanese began bombing his town of Qixian three days before he was born. As a child, he watched as soldiers of all the different warring sides-the Communist People’s Liberation Army, the Nationalist Kuomintang, and the Japanese—took turns filing through the town’s lone major road. His father was a businessman who later made a name for himself selling tea and often had to travel. Mr. Chen remembered that for some years, he would see his father only once a year. Fortunately, their family avoided major mishaps during the war years, but he remembers seeing body bags piled up by the side of the road. When World War II ended and the occupation by Japan ended, he recalled seeing people dancing in the streets.

Meanwhile, Mrs. Chen was born in 1938 in Tianjin in Northern China, one out of four children. Her father was a businessman, and her mother was a housewife. During the war years, her family moved regularly, living at different times in Sichuan, then Nanjing, and finally in Shanghai.

She had some recollection of planes flying overhead while she lived in Shanghai, and that her mother didn’t want her to attend school for fear of violence. But for the most part though, she didn’t see much of the violence of war firsthand.

Of course, the cycle of war in China didn’t end when the Japanese occupation ended. After the Japanese departed, the Chinese Civil War between the communists and the Kuomintang promptly resumed and only ended with the Communist Party victorious in 1949.

By liberation day of that year, Mr. Chen’s father had moved the family to Beijing. He was now a sixth grade student and heard the horns and sirens announcing the liberation of China. 

He would go on to continue his education in Beijing, and it was here that he witnessed the Chinese Cultural Revolution taking place. He was a university student in Beijing by the time the Cultural Revolution reached full swing, but he kept his nose out of politics and was not much directly affected. By now, there were no more actual classes in university. As engineering students, they spent time working in factories. He even recalled how during the Great Leap Forward, the students busied themselves with trying to figure out how to make iron into steel at Mao Zedong’s behest.

Meanwhile, Mrs. Chen had studied to become a mechanical engineer. She was one of only three women studying computers at her university, Tianda in 1960. She went on to study in an engineering school and then became a professor from 1961 until her retirement in 1998, at the age of 60.

Spread out over almost two decades, the Chinese Cultural Revolution under Mao Zedong marked the complete upending of all societal norms. Scholars were vilified. Universities were closed. Anyone with links to bourgeois thinking or a questionable family background was blacklisted. Countless people lost their lives and countless more lost their livelihoods.

Mr. and Mrs. Chen’s experience through the Cultural Revolution was notable mostly in that they managed to remain apolitical. Academics came under siege during the Mao era, and intellectuals were frequent targets of Mao’s reforms. They knew that it was better to avoid political conflict than to get into the heat of it.

When asked how he managed to survive this, he admits that he wasn’t that bothered by the political crises that surrounded them. He learned mostly to keep his mouth shut and keep out of trouble.

Mrs. Chen, meanwhile, became a scribe during meetings during the Cultural Revolution. In fact, she points out that her propensity for smiling and laughter showed up even here, as people identified her during these meetings as the “one who was always giggling.” On a more serious note, she remembers colleagues of hers who died during the years of infighting, but like her husband, she avoided most political issues herself.

Of course, all my elderly patients from China are survivors of the Cultural Revolution in one way, shape or form. And of course, there is a survivorship bias here. I’m talking to survivors, those who not only lived through it, but those who lived through China’s gradual rebuild, through Tiananmen Square, through Deng Xiaoping, and now live through to be able to tell their tales as Chinese Canadian immigrants.

Of course, while China was engulfed by these years of political upheaval, the Chens moved on with their personal lives. They had already met as university students but really got to know each other better in their final year of university. They ended up matching positions in Beijing together in 1962 and have been together ever since.

The Chens have two daughters, both of whom are now successful computer engineers with graduate degrees from prestigious North American universities. Their grandchildren are also studying to become engineers as well.

When her children were small, the Chens were busy as young academics. They were fortunate that Mrs. Chen’s hours weren’t long. She only taught two to three classes a week. Furthermore, the university had a kindergarten on site, and her mother came to help look after the grandchildren so that they could continue to work.

When asked about parenting tips, Mrs. Chen points out that they’ve been asked this very question many times by their friends over the years: “Your daughters are both so successful. However did you manage to inspire them?” 

Mrs. Chen tells me that she believes in parenting by example. She and her husband were both academics, so books were always plentiful in the house, and the parents could always be found reading. So, in time, the children saw them doing this and became intellectually curious themselves. “Don’t yell and berate,” she informs me. “That style of parenting doesn’t work anyways.”

What is unique about Mr. and Mrs. Chen’s immigration story is that while they have lived in Toronto for more than fifteen years, their two daughters have never lived here. This was a result of curious circumstances, but of particular relevance to our discussion.

When they first decided to come to North America to be closer to their children, one of their daughters was still studying in Manitoba and the other was on Long Island. Toronto, they reasoned, was roughly equidistant between Long Island and Winnipeg, and so they settled here.

A few years in though, their daughter in Manitoba married a Dutch husband, and before long, she had relocated to Holland to be closer to his family. This meant that the Chens would no longer be equidistant between the two daughters.

Still, rather than hinder their immigration experience, the fact that neither of their children are nearby seems to have strengthened their immigrant experience and actually gets to the root of how the Chens have thrived in Toronto. The Chens have never been reliant on their children. They made a point on arriving in Canada, to seek out the local LINC (Language Instruction for Newcomers to Canada) program, and began attending English classes on a regular basis. With no children to take them around, they’ve learned to make use of public transit. She tells me about how many of her fellow seniors at the community centre are reliant on their children to get around in Toronto. “They’re miserable,” she says. “They can’t do anything without their children.”

In my experience, many Chinese immigrants, even younger ones, pay only lip service to these offerings. With the influx of Chinese immigrants to Canada, it is possible to carry on a passable existence here and almost never speak English. But the passable existence has limits. You can rely on using exclusively Chinese-speaking service providers only so much, and there’s certainly a limit to how much patience your own children will have for acting as your translators.

The Chens moved into an apartment building near a bustling shopping centre, replete with a neighbouring Chinese grocery store and a large population of Chinese seniors. This is a far cry from other seniors like my own grandparents, who often end up living with their children in the suburbs, trapped on suburban streets where the nearest community centre or grocery store can’t easily be accessed except by cars which they cannot drive.

Through their English classes, the Chens became connected to various local Chinese community groups. Mrs. Chen proudly recalls that this was where she was introduced to me, having been informed that there was a local family physician who spoke Mandarin and was accepting new patients.

When asked what her overall sense of her immigrant journey is, Mrs. Chen tells me that she is most grateful for how she is treated by people in the Canadian service industries. A case in point: earlier in the week prior to our interview, she had received a notification of an error in her tax return from Revenue Canada. She took it upon herself to call Revenue Canada herself, and explained to me that in Canada, if she tells the agent on the other end of the line that her English isn’t very good, the person will invariably slow down and cheerfully take their time helping answer her questions. She says that this is a level of personal attention that simply doesn’t exist in China and is one of the things she is most grateful for here.

I think back to my own experiences dealing with the service industry, from my cellular provider to Revenue Canada. I’ve experienced many feelings when dealing with these people, but gratitude has never been near the top of the list.

These days, when the Chens visit their children in the US or in Holland, things are pleasant. Both of their daughters married foreigners. One of their son-in laws is Dutch and the other is American. They describe their son-in laws as both being extra polite, and extremely attentive to their daughter’s needs. But of course they would describe them this way. It only makes sense for such a happy couple to be able to get along just fine with their son-in-laws.

After sitting and talking to the Chens, I took away several ideas from their story. It seems that a stressful childhood environment does not preclude being happy and balanced as an adult. 

But the most remarkable trait of this amazing couple that I have learned is their willingness to adopt a growth mindset. I wonder who taught them this? Certainly, they grew up long before terms like growth and fixed mindsets became common parlance. I wonder if this comes from their background as educators. How else can I explain their willingness to come to Toronto, a country in a strange land where they had no existing family members? How else can I understand their enthusiasm for learning English at an age when many elderly are convinced that an old dog can no longer learn new tricks?

From this growth mindset, comes the steadfast determination to look after themselves and remain independent from their children. They know they can look after themselves, and their children know it too. In this day and age of complicated intra-family dynamics, when the best-selling psychology book on Amazon is titled Children of Emotionally Immature Parents, I realize the Chens have somehow figured all this out and they didn’t need a self-help book to do it.

We model ourselves, whether consciously or not on the people around us. When I was younger, I imagined that my life as a senior probably would mean living like my grandmothers: a lot of sitting around, imbibing television shows while grumbling about how nothing is quite as good as it was in the good old days. But then I think about the Chens, and it makes me realize that we’re never really too old to reinvent ourselves, or too old to move to a new country, or even too old to learn a new language. All is possible, as long as we remember to smile and laugh.

Web image by  Li Lin.

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 798

From Tigers to Otaku

09.16.25 1675

The Happiest Couple

07.28.25 1416

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 1994

One Patient, Two Systems 

02.24.25 2679

In my four years of Canadian medical school, I can only remember being taught four clinical pearls specific to Chinese patients. The first two were epidemiological facts: Hepatitis B is endemic in China and Chinese people have a higher incidence of nasopharyngeal carcinoma than non-Chinese. The third was an observation, that Chinese babies are often born with a large, purple discolouration on their buttocks that fades with time. These discolourations were pejoratively called Mongolian blue spots. 

The fourth clinical pearl was the strange one. I don’t remember much about the classroom content of first-year medical school, but this moment sticks with me even now, two decades on. In ethics class, we were learning about the concept of patient autonomy, the concept that patients have the right to make choices about their own health care. At this point, the ethicist mentioned to us that in many Asian cultures, especially Chinese and Japanese, people chose to forego autonomy and informed consent when it came to elderly family members and end of life care. What she meant was that Asian families often withheld information about the nature of their parents’ terminal illnesses from them for fear that by telling them parents the truth, their parents would feel irrevocably sad or upset, and that this might even hasten the progression of their illnesses. Until that day, I had never heard of this issue of withholding information from elderly family members before. As a Chinese Canadian, I had taken it for granted everyone would want to know the truth about their health when the time came. 

A few months after that talk, I was at home and broached the topic with my father. 

“Dad, they taught us that Chinese don’t like to tell elderly people that they are dying in order to protect them. Have you ever heard of this?” 

“Of course. You didn’t know about this?” He raised an eyebrow and gave me a look, as if surprised at how little I understood the world. “For Chinese people, we don’t talk about these things. If you know you are sick and dying, then your sickness will be worse.” 

My father was a learned man. He was a PhD in economics and had lived in North America for more than half his life. I expected more from him. “So you’re telling me that if it was you, you wouldn’t want to know?” 

“Of course I wouldn’t want to know.” 

His answer startled me. I had known that we had some different conceptions rooted in our different backgrounds, but for some reason, this caught me by surprise. I had expected him to share in my discovery of something that I presumed was backwards, old-fashioned Chinese thinking. But now it turned out that he was exactly the person being described in the ethics handbook. How little did I know of the world? How little did I know of my father? 

I dug out my first-year ethics textbook the other day and found the specific passage in question. On the subject of autonomy and Asian patients, the author Philip C. Hébert explains: 

When I read the passage over now, I can’t help but find it jarring. For an ethics textbook, the passage does seem to make the assumption that the western way of autonomy is the only right way. I wonder why I didn’t feel that way when I read the passage the first time so many years ago. 

This specific issue, that of telling an elderly family member about their diagnosis, became the basis of The Farewell, a 2019 film directed by Lulu Wang starring Awkwafina and Tzi Ma. The movie was loosely based on events from Wang’s own family life, in which an elderly grandmother is unaware that she’s been diagnosed with lung cancer. In the movie, the grandmother’s extended family decides that they want to have one last big family get-together but they can’t tell her about her diagnosis. They plot an elaborate fake wedding for one of the grandchildren and use it as an excuse to get everyone together. The movie is told from the vantage point of Billy Wang (played by Awkwafina,) the Americanized granddaughter who loves her grandmother and doesn’t really understand why they can’t tell her the truth. 

By the end, the movie settles on making the point that although the Chinese way of not telling the elderly about the diagnosis is different from what Billy is used to in the West, it isn’t necessarily worse, and it might even have its own merits. 

The movie wraps up with a postscript that Wang’s grandmother in real life is still living happily a good six years following her diagnosis. The movie implies that by not burdening her with the truth, the family has managed to improve the grandmother’s quality of life for at least these last few years, and hints that they might even have possibly affected the outcome of her illness and helped send the cancer into remission by not burdening her with the truth about cancer. 

In my own medical career working with Chinese immigrant patients, I have witnessed versions of this issue arise on several occasions. Several times, I have been asked by well-meaning children that “should anything serious ever happen to my mother or father, please do not inform them of the situation.” 

Sometimes, the request is gentler. “If any really important bad news needs to be broken to the parents, please let me know first and then we can discuss what to do about it.” 

As I’ve come to understand it, the reason for the request is a combination of things. There’s the obvious, overarching cultural basis to it. Confucius may not have ever specifically addressed the issue of whether people should withhold life-threatening medical diagnoses from their parents, but he did repeatedly underscore the value of filial piety and how one’s loyalty to one’s own parents should in some ways exceed their loyalty to themselves. So, in a way, not telling our parents the truth about their own mortality is just a little white lie to ease help ease a loved one through one of life’s inevitable travails. At least they’ll feel better not having to worry. 

This leads to the second reason, the belief that knowledge of one’s own mortality will almost certainly worsen any medical condition and hasten one’s demise. Given our own modern understanding that stress can make health worse, it does make sense to presume that fear about one’s own demise, very likely the greatest stress of all, could have deleterious health effects on a person who is already ill. 

Finally, sometimes the reason for requesting us to forego patient autonomy is simple pragmatism. Maybe mom or dad are unable to handle stress even at the best of times and we already know they won’t take the news well. In this case, shielding them from the truth might make a lot of things go more smoothly. 

In any case, when I’ve been presented with this scenario, as a Westerner, it’s difficult to dial down the urge to sit the patient’s family down and start channeling American police and cowboy movies. I can just imagine myself putting my hand on my holster and informing them that, “Ma’am, this isn’t the way we do things around here.” 

In my early years in practice, this is pretty much how I approached the problem, by understanding it as a purely cultural difference, and assuming that the ethics underpinning autonomy and informed consent should have universal application to all patients, regardless of cultural background. My understanding was that if you were living in Canada, then you had better accept that you had to do things the Canadian way. In short: when it comes to medical care, this is how we do it here. 

With that in mind, I’d sit down with the family member and explain to them that while we respected that other cultures could feel differently about this issue, this wasn’t really the way it’s done in the West. Then I’d present a compromise. “How about I ask your parent a hypothetical question along the lines of ‘if something were to happen to you, would you want to know about it?’” 

I’ve done this on several occasions in my career, and without fail, each time the elderly patient would contemplate the question for a moment before shaking their head and deciding that that no, they were better off not knowing the truth. 

What’s the big deal about all this? What happens if Grandmother or Grandfather doesn’t know the truth about their own illness? Is it really such a big problem if their child makes all the major medical decisions for them while they exist in a state of unknowing bliss? Isn’t that not that different than how parents often approach major medical decisions for an infant or a small child? 

And what about patients who explicitly abdicate responsibility for their own health at the eleventh hour? If the parent specifically says that they don’t want to know about their illness, then what? What are the implications of them ceding responsibility for this portion of their life to their loved ones? 

On a very basic pragmatic level, the parent not knowing about their own medical illness throws a monkey wrench into the basic efficiency of the health care encounter. In the West, certain aspects of health care depend on the patient being able to make informed choices, or at least depend on them having the knowledge of their illness. 

Imagine attempting to go for surgery or chemotherapy but not actually knowing that you have cancer. Imagine furthermore, that all the nurses and doctors who talk to you, who know full well that you are dying, cannot slip up even once and tell you the truth about what you are facing because once they spill the beans, there’s no putting anything back into Pandora’s box. 

Treatment decisions that might normally just be a quick conversation with a patient, now need to be run by an intermediary. Doctor visits that take ten minutes now take twenty minutes as a result.  

Furthermore, the practical effect of withholding information doesn’t end with health care. It applies even beyond the medical aspects of end-of-life care. Estate planning, inheritances, all the things that give grieving families around the world even more grief, are much more easily dealt with if the person who is dying is able to say what they actually want done. Except they can’t, if nobody actually is allowed to tell them that they are dying. 

There’s also this aspect from the family member’s standpoint: when a person agrees to make all medical decisions for their parent, they are agreeing to take responsibility for some decisions that are essentially impossible to make, especially when it pertains to end-of-life care. Should we perform heroic, but most likely futile measures on your parent? How hard is it for someone, even if they’ve had a full discussion with their parent, to be willing to make these life and death choices on behalf of their parent? 

Perhaps I’m giving away my Western upbringing, but I still can’t help but feel that there is something inauthentic about withholding the truth. Imagine living your days in an imagined reality where you believe you aren’t actually very sick, but you are. Without this end-of-life discussion experience, the person who is sick, and very likely their children, are not able to emotionally share life’s final journey together. Since it’s a journey that we all have to take, and it’s well-accepted that a serious illness or death in the family is one of the most difficult and stressful things that anyone has to go through, it only makes sense that if we can talk about it as a collective, surely we could deal with it better together than going through it alone. 

In the West, we are proud to have come up with these ethical principles that define our medical care. We laud the principles of autonomy and informed consent and look down at cultures that do things a different way. But as I’ve gotten older, I’ve noticed that in fact, Eastern and Western ideas about this aspect of medicine are not as dissimilar as we might presume. Yes, it’s true that in the West, as doctors we make a point to talk to the patient about death. We’re not afraid to tell a patient they have cancer, and we’re not afraid to try to tell them that the end is near. But at the same time, we usually stop right there and don’t say much beyond that. 

What does it actually mean to be dying? How does that make you feel? Is it scary? Do you have any regrets? Is there anything else you would like to do before you go? How does it make your children feel? Is there anything we can do to help with any of this? These are not conversations doctors typically have, but they seem to be at the heart of facing death honestly and authentically. 

The fact is we’re mostly not trained as doctors to have these conversations. Quite frankly, I’m not sure that most of us even have these conversations at home with our own families. It’s too easy, most times, when faced with these end-of-life crises, for doctors to leap into problem-solving mode. That is, after all, what we’re best at. End of life care sometimes becomes a series of day-to-day crises to manage. You’re having difficulty getting up? We’ll bring in a wheelchair. Constipated? There are so many pills for that. In pain? Good thing narcotics have been invented. As doctors, we’re trained to reflexively problem-solve. But sometimes, maybe what people need as they face death, is just someone to be present, to listen, and to talk to. Death may be inevitable, but it can still come with catharsis. 

Fortunately, the culture of Western medicine is changing. Conversations around death have become more normalized. The development of palliative care, a relatively new field of medicine that has appeared in the last several decades, has certainly helped this process. When it comes to death and dying, medicine in both the East and West still has much to learn, but at least we are trying. Maybe we will get where we need to be someday. 

My father was diagnosed with Alzheimer’s dementia in 2013. Shortly after he was diagnosed, we were faced with the issue of establishing power of attorney and determining what to do in the event of end-of-life care decisions. At the time, his illness wasn’t that severe, and he was a pleasant, if mildly confused, sixty-eight-year-old. He’d even been driving up to a few months prior. 

So one night, at dinner at my mother’s house with my sister and me present, we took out the power of attorney paperwork and gathered around the dinner table with him. I remembered how he’d told me so many years ago that he wouldn’t want to know if he was suffering from a terminal illness, so I tried to explain to him that we weren’t asking him these questions because anything was imminent, but just as a precaution for the distant, distant future; we wanted to know his wishes in advance. We asked him that in the event he became incapacitated, what would he want us to do? Did he want heroic measures like CPR and being put on a ventilator? 

I still remember him looking back at us, sheepishly, like a small child. It’s impossible to know just how much he understood in that moment. 

He smiled and said, “I guess if it’s already that bad, you don’t need to do anything.” 

Then he got up and shuffled off to the living room. 

I breathed a sigh of relief. It was obvious that, demented or not, it was a conversation that my father had not wanted to have. And the same went for me. 

I never talked to him about his diagnosis again. 

Web photo by Alexander Grey

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 798

From Tigers to Otaku

09.16.25 1675

The Happiest Couple

07.28.25 1416

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 1994

One Patient, Two Systems 

02.24.25 2679

Mrs. Lin is a fifty-five-year-old woman who has lived alone in Canada for many years while her husband lives back in China. Her two sons are both working and out of the house. Last week, she discovered a new breast lump while showering. A few days later, she’s in my clinic to get the lump checked. As her family doctor, I order a mammogram and an ultrasound. When the results of these tests come back a few days later, the report indicates that the findings are suspicious for malignancy and a biopsy is necessary. 

Mrs. Lin returns to the clinic and I relay the information to her. I try not to mention the word “cancer” to her, but it hangs between us, powerful even if it remains unsaid. I urge her not to jump to worst case scenarios, but we both know that one way or the other, this is life altering news. I promise to order a referral to the breast diagnostic clinic at the community hospital nearby and that the breast centre will reach out to her in the next week or two. 

Later in the week, I receive a fax from the breast clinic. They’ve been trying to reach my patient by phone but with no success. Do we have another way of contacting her? 

I instruct my office staff to try to reach the patient. They call repeatedly for a few days. The breast clinic appointment is scuttled but I’m not actually worried. I’ve seen this pattern many times before. I am certain the patient has already flown the coop. 

A few days later, my hunch is proven right. My nurse manages to reach one of Mrs. Lin’s sons. His mother is safely back in China, seeking medical attention there. They’ll call us when she returns sometime next year. 

When my father boarded a plane in Taiwan in 1967 to come to Canada on a one-way ticket for graduate school, my grandmother saw him off at the airport. She gave him $1000 and said, “I’ll see you in about ten years.” 

She wasn’t far off. In fact, he didn’t return to Taiwan until 1974, for his wedding. 

That was what being a Chinese-Canadian immigrant was like back in those days. A journey to the other side of the world was truly a journey into an unknown abyss. Letters marked “airmail” with the blue and red checkered envelope edges took weeks to circumnavigate the globe. If my father wanted to call his parents, he’d reserve the call for special occasions like Chinese New Year because long distance rates were exorbitant. And even then, he’d be careful to limit the call to one minute and fifty seconds because exceeding the two-minute mark meant paying unnecessary fees. 

Immigrating was essentially a one-way trip. Immigrants like my father rarely considered the prospect of flying back home because it was something most of them simply couldn’t afford. There were only two acceptable occasions to fly home: your own wedding or a death in the family. 

The journey for today’s Chinese-Canadian immigrants is different. Not only can they communicate easily with those back home using apps like WhatsApp, WeChat and Line on an hourly basis, but based on my observation of my Chinese Canadian immigrant patients, even those who struggle financially, seem to have a reserve fund that they can dip into and use to return to China on a moment’s notice. Home is never more than a one-day airplane flight away. 

And people fly back for all manner of reasons now: family illnesses, Chinese New Year, summer vacations, and most definitely, for expediting medical investigations. 

The fluidity with which patients move back and forth speaks to a difference in what motivates immigrants to come to Canada. When my parents’ generation left China or Taiwan or Hong Kong, often it was to trade a future bleak of possibilities for a possibly prosperous future. But for many of today’s Chinese immigrants, it’s a trade of one hopeful future, for possibly, a slightly better one, but with the option to go back if this future in the West doesn’t work out. 

Health care has become part of this back-and-forth fluidity. It used to be that the health care trade off would have been clear–Canadian health care was more advanced than that in China in the sixties and seventies. But that’s not entirely true anymore, and today’s immigrants arrive with a great deal more reticence about our health care system. 

Health care always presents unique challenges to an immigrant population. Illnesses imply a degree of immediacy and urgency. They play out on their own timetables – they don’t wait for people to become comfortable with the language or culture of a place before occurring. 

So the new immigrant is forced to face the health challenges of regular life—acute illnesses, chronic diseases, bodily injuries, babies being born, and even the occasional life-threatening-situation without the social support structure that they would have had back home. All this is part of the bargain that the new immigrant strikes with their adopted country. And so they pray that nothing major will befall them, but when something invariably does, what do they do? 

In the previous generations, immigrants here had little recourse but to seek out solutions in the Canadian health care system. Whether their English was up to snuff or not, they were forced to navigate the system here. Many Chinese immigrants like my parents flocked to Chinese-speaking doctors like me in the hope that at least less would be lost in translation if they found a Chinese person holding the stethoscope. 

The modern immigrant though, has the luxury of straddling the line between the Canadian and Chinese health care systems, keeping one foot in China’s health care system and another foot in Canada’s. 

Unhappy with the wait times for elective knee surgery in Ontario? No problem. A doctor in Taiwan or Hong Kong will have you on the table in the OR in a few weeks, not months. 

New discovery of lymphoma? No need to wait for your family doctor to refer you to an oncology clinic and for that clinic to send you for imaging before finally making a decision on treatment—a process that can easily span into months. If you fly back to China, you can walk into a specialty clinic the next day, see a doctor by lunch time and have imaging and an oncology plan done by the end of the week. 

When it comes to China, the western world has a tendency to see things in stark black and white terms: e.g., freedom is good and communism is bad. As a Chinese Canadian physician, I find that this type of thinking carries over to our view of the health care system. Medical students in Canada, are taught that the Canadian health care system is a virtuous, humane social experiment, one of the country’s proudest achievements. It’s drummed into us that it delivers world-class care to the majority of its people. And we’re proud to be trained in it. Sure, it has its problems, but nothing’s perfect. 

There is a hidden side to this curriculum though. If we’re world class here, what about health care systems in other places? What about Africa? What about South America? What about China? 

Perhaps unintentionally, we’re taught to look down on the systems of other countries. We use words like ”developing“ and “evolving” to describe health care systems in these places. But in private, we often shake our heads in exasperation and use far worse language than that. 

These stereotypes were only reinforced when I started practicing medicine about fifteen years ago. The requests of my Chinese patients, often rooted in their own experiences with the health care systems they had left behind, drove me batty on a daily basis. 

I’d try to explain to my patients that, “Yes, that might be the case there. But you don’t really need any of those things.” But it’s hard to convince someone that everything they’ve accepted as truth may not be correct. 

The worse complaint was always about the wait times. This was one that I could not refute. It’s well-known that wait times for medical procedures in Canada are criminally lengthy. But whereas my Canadian patients had nowhere else to go and would just vent to me about the breaking down of our country’s beloved health care system, or try to drive a few hours to Buffalo to get an MRI, my Chinese patients had the luxury of options. They could hop on a plane, land in China or Hong Kong or Taiwan by the end of the week and get whatever they wanted within days, not weeks or months. 

I should point out that the feedback from patients about the Canadian health care system wasn’t always negative when compared to back home. I learned that the fifteen to twenty minutes I allocated to speak to each patient was approximately twelve to eighteen minutes more than they got in the typical Chinese hospital. 

Still, there were many frustrations that I was unprepared for. Patients would return to my clinic armed with reams of paperwork (all in Chinese), documenting checkups and physical exams that they had done overseas: lab tests and CT scans that had no indication for being ordered, medications that they had been prescribed that were not really indicated. 

If modern medicine in the West suffers from an over-reliance on medical imaging and pharmaceuticals at the expense of a more prudent and holistic approach to care, then modern Chinese medicine has become Western medicine’s adopted twin, with all the same problems we have, except with even less sense of restraint and caution. 

Mr. Zhang is a middle aged, Chinese man with diabetes. In China, people routinely retire in their early fifties and one of the perks of retirement is long term health insurance, so even though Mr. Zhang has lived in Canada for almost fifteen years, he still can access Chinese health care whenever he is back home. 

Mr. Zhang isn’t alone in returning home to seek health care. Even those without health insurance often choose to pay out of pocket to access health care in China on a regular basis because the costs aren’t prohibitive 

Because Mr. Zhang travels back and forth between China and Canada on a regular basis (after all winters in Canada are cold), he needs doctors on both sides of the world to help him manage his long-term diabetes. What he’s discovered is that the quality of care in both countries is, for him at least, comparable. The general procedures for diabetes, routine blood testing, and medication adjustments, are similar in both places. But there are some noticeable differences. 

He informs me that in China, the health care system is heavily incentivized by the profit motive. Hospitals make more money if they achieve certain revenue quotas, and this is passed on to the doctors, who in turn pass this mindset down to the patients. 

At the same time, it’s well known to him and all his friends, that in Canada, with a public health care system, cost-cutting is much more of an issue. 

The doctor as gatekeepers of the health care system is sometimes a difficult concept for patients to understand. Doctors in China are not really gatekeepers of the system the way they are in Canada, where doctors spend a great deal of time being instructed on not over-ordering tests. Not all medical investigations are necessary. Extra tests beget extra costs and may engender unnecessary anxiety and have deleterious consequences for the patient-just think about the patient who worries about a lung nodule that will never cause them problems once it’s been spotted on an unnecessary chest X-ray. These are hard lessons that even medical practitioners in the West struggle with at times. For my patients from China, this concept is irrelevant. In a privatized system where patients can pay for what they want, getting an unnecessary MRI is no different than spending money on a fancier car or an extra helping of dessert: nobody really needs it, but if they can afford it, then why not? 

So if I try to explain to my patients why I don’t think they need that MRI they really want, they think I am just trying to save the government of Canada money. If I am really hard-nosed about it, they just might turn around, get on a plane and have the test done in Shanghai or Taipei by the end of the week. 

In China, if I want an MRI and can afford to pay for one, then who is anyone to stop me from getting what I want? If a cardiologist makes more money for pushing a certain type of stent at a patient, who is going to stop them from recommending it to patients who might do just as well with a less aggressive intervention? 

To be sure, these are problems that exist in many parts of the world, even here. But reviewing the stacks of lab results and CT scans that my patients lug back to Canada from overseas, I can’t help but feel that my patients have stumbled upon the Wild, Wild, West of health care-except it’s in the Far East. 

There is of course a downside when patients straddle two countries for their healthcare. Countless times, I’ve had patients return from overseas after having had a major health calamity. Maybe they had breast cancer diagnosed in China, or a screw placed in their hip after a fall, but now that they’ve returned to Canada, no specialist office will see them.  

Dutifully, the patient brings copies of their hospital notes from China, copies of their CT scans and MRIs, but nobody here is willing to read them because nobody here trusts what the report says. If the documents are written in Chinese, Canadian doctors usually can’t read it. Even if they could and wanted to trust it, can they really do so medico-legally? And so it’s the patient that gets left in the lurch.  

In the end, armed with a Chinese-Canadian dictionary in my early years in practise, or more recently Google translate, I’ve learned to muddle through. With my admin staff translating the documents for me, I can usually piece together what procedure a patient has had done overseas. Then we try to match them with the appropriate follow up here, often repeating the testing and imaging so that patients can access care here. 

But it’s getting better. In my early years, I couldn’t find any oncology clinics willing to follow my patients who had started their chemotherapy overseas. Many of these patients flew all the way here to use their hard-won Ontario health care card, only to have to fly back home shortly thereafter when they realized they weren’t going to receive timely care in Canada. These days, I’ve seen more care handoffs take place here smoothly. Truly, the health care world is becoming a little friendlier to immigrants. 

It used to drive me crazy when my patients sought out health care overseas. In medical school, we’re taught a very idealized version of medical care, something akin to the traditional country doctor’s life straight out of the 19th century. A patient feels unwell. They seek out a local physician. The physician solves the problem or directs them to someone else who can. The problem is solved, and life goes on. 

But in real life, I saw that patients didn’t always stay in one place. Sometimes they asked me for help first. Then they’d go overseas. At other times, they came back from Asia and needed my help deciphering what had happened to them there. And back and forth they went. 

Sometimes I’d get exasperated that they were receiving substandard care overseas. At other times, I’d gain an appreciation that they really could get better, faster treatment for certain things in China that in Canada would have taken ages. In time, I developed a grudging respect for health care in China. 

As I worked with patients who were navigating these two systems simultaneously, I felt myself drawn into a curious, political dilemma. Which health care system is better? 

Sometimes patients would pull me aside and ask me what they should do, fly back to China and seek urgent care or wait a bit longer to see their specialist here in Canada? 

The issues were always some variation of the same theme, a weighing of trade-offs: comfort with the language, wait times, medical expertise, as well as the family support system, all bundled into one massive equation that boiled down to a simple binary question: China or Canada? 

I’ve found my own stance on the issue change over time. When I first graduated from medical school, armed with all my pro-Western biases, the answer was almost certainly Canada. 

But in recent years, I’ve watched medicine advance in China from afar, through what my patients tell me, and through the medical records and histories that they bring back to me. Perhaps there’s still a lot of overkill in investigations on the other side of the ocean, but often the quality of medicine isn’t that different from what it is here. And it’s almost certainly faster. And if you can pay for quicker care, why not? Moreover, many of these Chinese immigrants have family support networks back home that simply don’t exist here. For them to return home for their care simply makes rational sense. Nothing reminds someone of how foreign they are as being in a cold, sterile hospital environment where nobody speaks your language. 

More than a year after she departed, Mrs. Lin returns to my clinic. Following a lumpectomy and ten rounds of chemotherapy, the doctors in China have instructed her to remain on estrogen receptor therapy for the next five years. 

Why did she return to China for medical care? Despite living in Canada for more than a decade and having a passable command of the English language, she still felt that for something as serious as this, she wanted to be someplace she could speak her native tongue. Plus, she would have family members there to support her. Left unsaid is that the entire medical procedure in China took days to arrange not weeks as it would have here. 

I refer her to a medical oncologist, who reports back to me that she is overall, in agreement with the patient’s treatment plan. She replaces the patient’s estrogen treatment with an alternative agent that is available in Canada. 

Web photo by Zac Ong 

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 798

From Tigers to Otaku

09.16.25 1675

The Happiest Couple

07.28.25 1416

The Things We Don’t Talk About When We Talk About Dying 

05.13.25 1994

One Patient, Two Systems 

02.24.25 2679