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 

01.12.26 918

From Tigers to Otaku

09.16.25 1811

The Happiest Couple

07.28.25 1528

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

05.13.25 2113

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 

01.12.26 918

From Tigers to Otaku

09.16.25 1811

The Happiest Couple

07.28.25 1528

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

05.13.25 2113

One Patient, Two Systems 

02.24.25 2805

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 

01.12.26 918

From Tigers to Otaku

09.16.25 1811

The Happiest Couple

07.28.25 1528

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

05.13.25 2113

One Patient, Two Systems 

02.24.25 2805

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 

01.12.26 918

From Tigers to Otaku

09.16.25 1811

The Happiest Couple

07.28.25 1528

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

05.13.25 2113

One Patient, Two Systems 

02.24.25 2805

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 

01.12.26 918

From Tigers to Otaku

09.16.25 1811

The Happiest Couple

07.28.25 1528

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

05.13.25 2113

One Patient, Two Systems 

02.24.25 2805

The place: a nondescript, ramshackle medical clinic located on the second floor of a large Chinese mall, located in the suburbs of Toronto, just north of the city, circa 2008. 

Our narrator, the protagonist, is a newly minted family physician, a Chinese Canadian who grew up not far from this neighbourhood. 

On this otherwise nondescript morning, I get into the office and find that the first patient of the day is already waiting for me. 

On my way into exam room eight, I grab the large patient file that sits in the file holder just outside the door. Many of these files are for longstanding patients of the clinic, and even though I’ve only been working at the clinic for just over a year now, I’ve basically inherited them and their problems from the doctors who worked shifts here before me. 

Inside the room are two middle aged Chinese men. One is a stocky, heavy built man in work clothes. Next to him is a clean-shaven man wearing a dress shirt and slacks. I vaguely recognize the larger man. I’ve definitely seen him before. I’m not sure who his friend is. 

The two men greet me enthusiastically. 

“Good morning doctor,” says the man I recognize. 

“Here, we bought you a cup of coffee,” says the other man. He points at a styrofoam cup of Chinese mall coffee that is sitting on my desk. 

I nod and smile. It occurs to me that it is odd that they are so friendly. But it won’t be the last odd thing to happen to me on this day. 

“What brings you in today?” I ask in Mandarin. I’ve gotten used to speaking Mandarin during the majority of my patient encounters at this clinic. In fact, I’ve spoken more Mandarin since I started this job than I have in the preceding ten years, maybe since childhood when I spent a year living in Taiwan. 

The man in the dress shirt speaks. “Do you remember filling out a life insurance application for him recently?” 

As he speaks, I open the manila folder and start flipping through the chart to orient myself. I do remember this chart. The patient, the blue-collar worker, is not a regular patient of mine. I’ve only seen him once or twice in the past over the last few months, for prescription refills, and a discussion about his hypertension. Most of the chart, years and years of doctor visits, predates me. 

A month or two earlier, a request came in from an insurance company, asking me to provide a letter documenting the patient’s medical record. Insurance companies use these records to determine if a patient should qualify for life insurance, or how much of a premium they should pay based on their pre-existing medical conditions. 

“Yes. I do remember filling this out for you.” It is starting to dawn on me what the purpose of this visit is. The problem here is that the patient has a long history of high blood pressure, and he’s been consistently noncompliant with his treatment. I flip further back through the chart. There are multiple records of high blood pressure readings over the years, and lists of medications that were prescribed that he never ended up taking. 

All of this was documented in the note that I sent back to the insurance company last month when they asked me for a record of the patient’s medical history. 

Now it’s the patient’s turn to speak. “I don’t understand why I didn’t qualify for insurance. I have no health problems. What did you write on the insurance application?” 

I brace myself. I know he won’t like the answer. “I didn’t write anything special. I just told them what happened at your doctor visits based on what is written in the chart.” 

“You told them that I have high blood pressure?” 

“You did have high blood pressure at the last visit.” I turn the notes to the page from the last visit. “Your blood pressure was 154/96 at the last visit.” 

“I don’t have high blood pressure. I feel fine.” 

Of course, the patient feels fine. Hypertension is a silent disease. Patients usually don’t feel anything. 

“Why don’t you check my blood pressure now? I’ll prove to you that I’m fine.” 

I can feel myself start to tense up. I’m not really sure how to extricate myself from this situation. I agree to check his blood pressure as a way to buy myself some time. 

I put his arm inside the blood pressure cuff and pump the cuff. I use the silence to think about what I should do next but there isn’t enough time. Nothing comes to me. 

Not surprisingly, the reading is elevated.  

“160/100” I report. I try not to sound too triumphant. “It’s still high.” 

The patient ponders this for a moment. 

The friend decides to try a different tack. “Doctor, my friend here is trying to apply for health insurance. Can you please help us out? “ 

“I’m not sure how I can help.” As I say this, I look up and notice once again, the styrofoam cup of coffee. Now I see the gift for what it is. A payout or a bribe. Either way, something dirty. 

“If you can just write a letter explaining that he is healthy and he doesn’t have these issues, we can take it to the insurance company. Please help us out.” 

I have to choose my words carefully here. It’s harder for me to do this in Mandarin and I wish I could speak English here. “I can’t do that. It’s in the file. I can’t change the record.” I open the file and show the two men. The patient has a long history of high blood pressure. It isn’t one reading, or one visit, but a pattern of high readings over many years. I try to explain this in as simple Mandarin as I can. 

“Really? All we need is just a letter, explaining that he is healthy.” 

For a moment, I’m tempted to write them a letter, just to get them out the door. But what purpose would it serve? There’s no way around the fact that the insurance company has already received my prior correspondence clearly documenting the high blood pressure readings. I can’t lie to them. I think about my medical license, my career, and the prospect of losing it all over a two-dollar styrofoam cup of coffee. 

I shake my head. “I can’t do it.” 

In medical school, we attend classes on how to conduct patient interviews. We’re taught ways to de-escalate angry patients who are upset about things like having waited too long in the waiting room. For patient visits that are spiraling out of control, we’re taught the importance of body language. If a visit is going nowhere, we’re taught to stand up and move towards the door. This will suggest to the patient that this discussion is coming to an end. So this is what I do. I get up and move towards the door. 

The patient and his friend look offended. “Why are you getting up? We’re not done talking.” 

I’m now feeling very edgy. Medical school didn’t teach me what to do in this situation. A pit is forming in the bottom of my stomach. My sympathetic nervous system has kicked into overdrive. 

“I don’t have anything more to say.” I manage to force out this sentence in slow, stilted Mandarin, but my stomach is churning. 

“Why can’t you help us?” 

“I didn’t say I can’t help you. But you’re asking me to do something I can’t do.” 

“You’re a doctor. A doctor is supposed to help people.” 

I’m lost for words now. I stare back at the patient, the gears in my brain spinning frantically but to no avail. 

“You call yourself a doctor? What kind of doctor are you?” 

In our training, we’re taught a formula of what to say to patients in this type of situation. If a total breakdown in communication with a patient occurs (I’m pretty sure when a patient is pressuring the doctor to do something illegal and unethical, this would be grounds for a total breakdown), we’re taught to say something along the lines of “I feel like we’re having a breakdown in the patient-physician relationship, and we cannot continue this way. It might be best if you find another doctor to try to help you.” Right. You try translating that sentence into Mandarin. You try translating that sentence when a large, Mandarin-speaking man is breathing down your neck and asking you what kind of doctor are you? 

I try to come up with that sentence, but all my years of spoken Mandarin at the dinner table with my parents, and two years of university level Chinese fail me in that moment. 

I’m trying to say that our relationship is breaking down, but what actually comes out of my mouth is this sentence: 

我不喜欢你的态度  

This translates roughly into “I do not like your attitude.” In hindsight, maybe the sentence sounds too much like how a parent might lecture their teenage son when said son refuses to take off his headphones to hear whatever lecture the parent is offering. Or maybe it’s simpler than that, that maybe nobody likes being told that they have an attitude problem. Or maybe it was just the moment. I’ll never know for sure. 

In the next instant, the patient leaps up and charges at me. 

Terrified, I bolt out of the room. Luckily, I am already at the door of the exam room and in an instant, I am down the corridor, with the patient hot on my heels. Near the end of the hall, a friend of mine, another doctor in the clinic, comes out of his room to see what the commotion is about, and manages to get between the patient and myself, giving me a moment to flee to the relative safety of the computer room in the back of the clinic. I shut the door behind me. 

Outside, I hear the ruckus continue. My friend and one of the receptionists are trying to talk the patient off the ledge while the patient is hurling epithets at me in Mandarin. As I stand there, my entire future career flashes before my eyes. I tell myself this: if he makes it into the room, do not throw the first punch under any circumstances. But if he throws the first punch, then what? 

Over the years, I’ve been asked many times what it’s like working almost entirely with Chinese patients in a language that isn’t my native tongue. I’ve even given talks to the Medical Mandarin club at the University of Toronto about how to conduct medical interviews in Mandarin, and I have a few prepared answers for the students. But the full truth is too hard to explain. Only this incident can explain it. 

The truth is that I speak Mandarin well for a Chinese-born Canadian but compared to a native speaker, I am only just getting by. I can order food at a restaurant. I can understand television dramas from China and Taiwan. I can even haggle with a salesperson over the price of a speaker system if need be. 

In time, my medical Mandarin has improved too. When I started, I only knew a few medical catchphrases that my parents spoke at home. I knew how to say, “Hepatitis B” and “cholesterol” and “blood sugar.” The rest of the terms, I gradually learned from my patients over the years, as we talked about erectile dysfunction, menopause, thyroids, and everything else under the sun. 

All of this is great for my vocabulary, but the truth is that anyone can order dishes off a menu if they practice enough times, and the rote conversations that fill Mandarin textbooks and audio Mandarin lessons can be memorized and rehearsed until one can fool most people into thinking one is proficient. What I’ve learned about languages from medicine, and most specifically, through this incident, is that true mastery of a language should also include being able to nimbly think up an intelligent, appropriate response when one is under emotional pressure. 

Thankfully, this scenario doesn’t occur that often. In the years since, I’ve had to teach myself to be very, very careful when having emotionally charged conversations. And over time, I learned a technique that I could deploy now if necessary. If a situation like this encounter were to recur in the future, I would stick to English to avoid miscommunication and to retain control of the conversation.  

Fortunately, the office manager managed to talk the patient into calming down and the door to the computer room was not barged through, and there were no fisticuffs. It was, to date, the closest I’ve ever come to physical blows in my adult life. The patient had initially demanded that I come out and apologize, and insisted they would wait outside the office until I reappeared. But eventually, the manager explained to the patient that if he kept on threatening the office, we might just have to call the police. 

As for me, for a few weeks thereafter, I thought twice about walking down the long corridor to the underground parking lot alone, but time passed and eventually this incident moved out of the forefront of my mind and life went on. I never saw the patient or his friend again. 

Web Image by Brando Makes Branding

Additional Chapters from A Chinese City Doctor’s Notebook

When Your Body Isn’t Yours 

01.12.26 918

From Tigers to Otaku

09.16.25 1811

The Happiest Couple

07.28.25 1528

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

05.13.25 2113

One Patient, Two Systems 

02.24.25 2805