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 

01.12.26 692

From Tigers to Otaku

09.16.25 1544

The Happiest Couple

07.28.25 1296

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

05.13.25 1877

One Patient, Two Systems 

02.24.25 2540

On the latest episode of Apollo On Call, I am pleased to welcome my good friend and pop culture expert Dr. Stuart Harman, a paediatric emergency room physician from Ottawa, Canada, to discuss the breakout TV medical drama of the moment: The PITT. 

Both Stu and I have watched about three quarters of the show’s 15 episode first season at the time of recording this podcast, enough that we are ready to weigh in on some important medical humanities questions. Is The PITT realistic? Does it reflect the reality of life as an emergency room physician? Which parts of the show make sense and which don’t? What does it say about the hierarchal world of a teaching hospital? 

If you haven’t watched The PITT yet or are considering whether you should watch it, this is the episode for you. We deliberately avoid any spoilers and instead talk big picture about the show’s themes and place in medical humanities. 

Have a listen, and then come back in a month or two, when Stu and I catch up after we’ve finished the season. Next time, spoilers will be on so you better come prepared! 

David Hsu 

The Pitt Trailer

Images of Mats Sheen and Ibelin from Mats’ Facebook page and Medieoperatørene / Euforia

A child of unconventional, British-born parents, raised in the bucolic countryside of Vancouver Island, British Columbia, her relentless pursuit of science began in a love of animals, carrying her through two Canadian universities to a University of Chicago PhD in pharmacology and tenuous postdoctoral positions investigating the pituitaries of whales and armadillos. The research sent her to sea with grudging whalers and to inhospitable deserts by night. She married fellow pharmacologist Ellis Kelsey, followed him for his work, and became a mother of two daughters. Lack of paid opportunities for a woman scientist sent her commuting to medical school in Chicago where she obtained an MD degree in 1950 at age 36, while her husband kept the home and family together. She was working as a G.P. locum tenens and as an editor for JAMA. After a stint in South Dakota, the family relocated to Washington in 1960 where she began her lengthy career in the FDA, rising through the ranks to positions of prominence. Not long after the move, her stance on thalidomide earned her the Distinguished Federal Service Award of 1962, presented by President J​ohn​​ ​F. Kennedy. It also brought widespread admiration, mountains of fan mail, several other honours, and the resentment of male colleagues. Ellis died suddenly in 1966, but she kept working into her 90s, taking on the public-health challenges of other notorious “remedies” seeking approval. Kelsey’s fame eventually subsided but rose again in 2015 with late honours and her death at 101 years of age.  

Cheryl Krasnick Warsh​,​ who lives and works on Kelsey’s parental home of Vancouver Island, has given us a wonderful biography. With many previous publications in gender history and the history of alcohol and other drugs, Warsh is well placed to handle this vast and ​multifaceted​​ ​topic, sensitive to the misogyny of Kelsey’s century and with expertise on the nature and fortunes of licit and illicit substances.  

In twenty short chapters, Warsh divides this long life into three ​​segments– before​,​ during, and after thalidomide– and identifies her subject in three different ways. She describes “Frankie’s” early years in simple prose, reminiscent perhaps of Gertrude Stein or Emily Carr. Quirks and disputes in the Oldham home become evidence of a high-functioning, dysfunctional family. As a young woman, “Frances Oldham” delved into science studies at what would become University of Victoria and McG​i​ll in Montreal but made the ​trip ​back home every summer. She slipped into the laboratory of distinguished pharmacologist E.M.K. Geiling at the University of Chicago, when he believed the applicant was male. Despite his initial skepticism, Geiling fostered her career and supervised her doctorate. In 1937, she worked on the lethal side-effects of elixir sulfanilamide and determined that the solvent was responsible. At that time, she also became interested in researching harmful effects of pharmaceuticals on pregnancy and explored the legal protections (or lack thereof) for their consumers. With Geiling and Ellis Kelsey, Frances Oldham wrote a pharmacology textbook, one of the first in America, that went into four editions. These experiences, her medical degree and the work with JAMA were excellent preparations for her concerns about thalidomide. Now she was “Dr Kelsey,” one of two in the same home. 

Kelsey first doubted the value of this new drug when the side effect of peripheral nerve damage seemed to have been excluded from the incomplete applications and their inadequate trials. Further delay allowed for the early reports of fetal damage (coming from newspapers rather than manufacturers) to add to the concerns. While she succeeded in blocking the approval of thalidomide, it had managed to make its way into the US anyway, in the form of free samples given to practitioners sloppily engaged as researchers in shoddy “clinical trials.” Warsh carefully tracks the resultant American harm through reports of at least 56 damaged or dead infants documented in a survey of city health officers in 1962—probably merely the tip of an iceberg. She also probed the tragedy’s impact on attitudes to abortion, respect for the disabled, and increasing caution over medications. 

Beyond the thalidomide story, this biography provides a good sense of the evolving field of pharmacology and interesting chapters on the thorny history of several famous drugs–Krebiozen, laetrile, dimethyl sulfoxide (DMSO), artificial sweeteners, and diethylstilbestrol (DES)–and the harmful impact of Xrays on the pregnant belly. Kelsey found support from other women scientists, in particular Barbara Moulton and Helen Taussig​,​ who became her friends. 

Warsh has tapped into a wealth of sources—extending well beyond the numerous publications, FDA documents, and newspaper reports. She interviewed Kelsey, aged 99, in 2014 and spoke with her colleagues, daughters and other family members. She made excellent use of the personal papers, sorted by the pharmacologist herself with the help of FDA historian John Swann; they contain more than 78,000 items and occupy more than 100 feet of shelving in the Library of Congress. Moreover, Warsh follows the court decisions, changing legislation and rules governing not only drug approvals but ​also ​the ordering of female lives in terms of employment and reproductive freedoms. Yet she handles all this information with a deft light touch, accessible language and playful humour.  

A great read about a great scientist and a fascinating era in biomedical science. 

Frances Oldham Kelsey, the FDA, and the Battle Against Thalidomide
Warsh, Cheryl Krasnick
Oxford University Press. 
New York, 2024-03-15

Photos of Frances Oldham Kelsey from Wikicommons

Cheryl Krasnick Warsh Interviewed at Library of Congress

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 

01.12.26 692

From Tigers to Otaku

09.16.25 1544

The Happiest Couple

07.28.25 1296

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

05.13.25 1877

One Patient, Two Systems 

02.24.25 2540

This is an edited transcript of the zoom interview.  

JD: Hello, everyone. I’m Jacalyn Duffin at Queen’s University in Kingston, Ontario. I’m a retired hematologist and historian. Kingston is situated on the traditional lands of the Haudenosaunee and Anishinaabeg peoples. And today I’m chatting with my friend and colleague, Darrel Manitowabi, who is a professor at the Northern Ontario School of Medicine University. 

Darrel, tell us about yourself and your job. 

DM: Greetings, everyone. I would say in Anishinaabamowen [indigenous language]. Thank you all for listening to this. My name is Darrel Manitowabi. I am Three Fires Anishinaabe from Manitoulin Island. More specifically, Wiikwemkoong Unceded Territory, which is on the eastern end of Manitoulin Island and Georgian Bay. 

I currently live in Whitefish River First Nation, which is just across from the island on the mainland in the traditional territory of the Robinson-Huron Treaty. And I am currently the Jason A. Hannah Chair in the History of Indigenous Traditional Medicine and Indigenous Health in the Human Sciences Division at the Northern Ontario School of Medicine University. The acronym for short is NOSM [pron: naw-zim]. And that’s who I am. 

JD: Thank you. I’d like to mention also that it’s a very beautiful, sunny, but extremely cold winter day here in Kingston. We’re at minus 16 degrees centigrade. How about you? 

DM: We are about minus 20 Centigrade, I believe the last I checked, I’m in Whitefish River First Nation as I shared and so, it’s rather cold here, and it’s the coldest time of the year thus far. 

JD: Yes, for us too. And for the Americans listening, that’s about zero degrees Fahrenheit. Can you tell us a bit about your job. You started in 2020. That was right in the middle of the pandemic, basically. And you are the inaugural professor in that chair. Can you tell us about what you were supposed to do at NOSM? 

DM: As you stated, I joined in the time of COVID, which is a less than ideal time, especially when you’re starting a new job. There’s intermittent openings, which is very difficult for someone who needs to access a library. 

One of the more recent collaborations I had just by way of example is with Dr. Geoff Hudson, who is a historian of medicine at the medical school, we have a chapter in the book, An Accidental History of Canada [McGill-Queen’s University Press, 2024). And we wrote about Manitoulin Island accidents from settler and indigenous perspectives. And it was the most difficult chapter I’ve ever had to write because I couldn’t access anything. Everything was closed. And when it was open, it was only for a narrow window. It almost felt as though you needed to expedite your process, right? And that’s how I would describe that initial experience just by way of example.  

A lot of my work involves working with elders and traditional healers. My approach to this Chair is quite a bit different than it has been in the past. I’ll just give you another example of that. When I first started this chair, I went to the indigenous community to help inform the kind of work I would do. Typically, an academic embraces autonomy and academic freedom and all those sorts of things and goes about doing things that are in part conditioned by the academy and the expectations of that. I reversed that and I took an approach wherein I am conditioned and in sync with community. And one of the things that community determined to be important is to build capacity in understanding traditional healing and its place within contemporary society and that involves coming together. So, since 2020, I’ve been consulting with elders, traditional healers, and we’ve been determining a pathway forward. And it’s a continuous preparatory aspect of the work that I’m doing, I’ve been focused mostly on that.  

I consider my approach to be a kind of a two eyed seeing, which is this perspective of blending Western knowledge with indigenous knowledge. But the way that I’ve operationalized it is I’m blending university logic and expectations with community logic and expectations. And I try to do enough of the university stuff to satisfy those eyes and I also concentrate the balance of my time with community. So it’s a juggling act. It’s a balancing act, recognizing that there’s an incompatibility in essence with how community sees knowledge production and would like to see it done and how the university does. The university is a hierarchical individualized process whereas in community it’s more of a collective process. We do things together. We are a collective group of authors and collaborators rather than a hierarchical individual leading a group. I’m not leading anyone when I’m in community. I’m working alongside. That’s what I’m doing there. And Indigenous Medicine Stories –what we’re going to talk about here– is the essence of what that means. It’s a kind of bridging of those two worlds. It’s like bridging those two ways of experiencing and practicing knowledge. 

JD: Well, right away you’ve kind of explained to me the origin of Indigenous Medicine Stories they seem to be an extrapolation of what you envisaged your job to be. Did you have the idea before you went for that job or was it something that came to you while you were inventing what you should be at NOSM? 

DM: I’ll come back to COVID. COVID explains a lot. During COVID, we needed to modify our curriculum to reflect remote learning. And given the work that we were doing, we do a lot of experiential stuff, having elders come into the classroom. 

At the medical school in year one, there was even an indigenous placement that that became a bit of a challenge. We ended up doing things like everyone else in front of a computer screen. And that’s a challenge with learning. It’s exhausting. I remember those long days of just staring at my computer screen doing presentations and not having that human connection. And a few of the students had raised a question that we should consider alternative ways of experiencing this learning. 

And one or more (I can’t remember if it was one or two or more than that) mentioned podcasts. And I thought, that’s an interesting idea. And at the same time, I was thinking about a project that involved collections of life histories of elders and healers akin to a book by David Newhouse and Don McCaskill, that was, In the Words of Elders Aboriginal Cultures in Transition [U Toronto Press, 1999). They essentially traveled across Canada and they collected life stories of elders from across Canada. And it’s literally their life story. It’s their narrative that forms the basis of each chapter. And also this other project that took place, the Indian Film Project that was at the University of Regina, the Canadian Plains Research Center. And what they did is they traveled across …or someone traveled across Canada. It wasn’t always the same person. And they sat down with people of significance of indigenous ancestry who might have been an elder or a leader or a healer, and they just asked questions, and they collected a transcript of what their experience was like. And it almost seemed as though it was a bit of a random process that you weren’t quite sure what the purpose of that interview was, but it produced a lot of important information and an important historical record. Many of those individuals are no longer with us now. It’s become an important archive. And so when I was thinking about those three things all at once, the concept of a podcast came about and I thought I could have guests speak about their experiences in their own words. And I could generate an archival record by way of the voice, but also by way of the transcript.  

I was having a conversation with Anne Avery at the Associated Medical Services, and she had mentioned that they had done a podcast. We continued talking and came to the conclusion, why not collaborate? Why not work together on this? That’s how it all came about. But it was it was the intersection of all of those things that were happening that led to this. 

As I thought about it further, and I’ll just expand upon this, one of the things that I consider to be an interesting aspect of the podcast and of the approach that I take is having the guests speak about themselves in their own words, which also reflects back to what I mentioned before in the sense that I try to speak as little as possible and I try to highlight the voice of the person, have the person talk about their life in their own words, on their own terms. And I’m merely a conduit to that or a bridge to opening the door of understanding. 

It also reflects the fact that academia traditionally and in the research that I’ve done, I do a lot of oral history research where I speak with elders. And one of the frustrations I’ve always had is that they have so much important ideas to share. But I must edit things down to one or two sentences or perhaps if I’m lucky, five sentences. And I thought, there needs to be a mechanism or a medium by which that comes to an end. That was also an aspect of it. But it’s also that relationship. I don’t see this as being the authority over. I see this as a visit, a way to learn and to engage. And I also specifically approach it by way of highlighting the life history. Quite often elders, academics, and others are called upon to do something specific to their job, whether if you’re an elder, you’re doing a teaching, or if you’re a researcher, you’re discussing your research. Rarely do we ever have a chance to understand where are you coming from? Who are you? Where did you grow up? Who were your teachers? What was that like? And so it’s really about them telling their story. It became a way for me to to navigate or balance or weave in this interface of the university and the community in a creative way that allows for that outcome. And one of the significant aspects as well is the educational component. And it links to my chair, the AMS chair. One of the features of it is to help –And you might have your own perspective on this, Jackie, because you’ve had a longstanding chair–is to [help] find ways of inserting these kinds of perspectives in medical school curriculum by way of encouraging research with students or advancing curriculum in a particular kind of way. Doing scholarly activities and creative work such as this helps to demonstrate to biomedically inclined future physicians that there is a humanistic aspect to healing and medicine and also an historical aspect. Those are all coming together and are all influencing how things came to be. So that’s a little bit of an insight into the origin. 

JD: Well, for those who haven’t been to look at Indigenous Medicine Stories–and we will certainly explain at MedHum how to find them–they are a wonderful cluster of podcasts. They’re not short. They run up to an hour or so. And right now there’s about 22 of them there You’ve already answered some of my questions about not only where it came from, but how it can be used. I’m interested in if it is difficult to get people to talk. I know you have a PhD in anthropology, and I believe you used oral history to get there when you were writing your thesis. But is it difficult to encourage people to talk, especially if they’re being recorded? 

And one quick question. Tell us about that beautiful image you have behind you, which is the title page of Indigenous Medicine Stories. 

DM: let me get to the title page, the artwork first, then I’ll jump into that. I needed a logo and at the time I was searching for ideas and one of one of the initial concepts I had was to take a picture of medicines. And so I did that but there’s a young community member where I live here, Whitefish River First Nation, a young aspiring artist by the name of Nevada Anwahtin. Nevada had a collection of paintings, and I just was interested in seeing if she had something that kind of really connected. And once I saw this, I knew right away that it was the perfect piece of art that would serve as a logo. And it also represents the future because it’s from a young Indigenous artist who’s a female. 

And also, it reflects ceremony. The image is of us, of what we understand to be a sweat lodge. There’s different words for that word. But anyways, it’s a sweat lodge and there’s a vision that is coming out, this is my interpretation. Nevada will have her own inspiration and interpretation. But this is what I saw when I looked at it. It’s engaging with the spiritual essence of ceremony and it’s in beautiful colors. So I thought, this is the art work that I needed. That’s how that decision was made. And to answer your next question about Is it difficult? I would say in part what I’m trying to do is to capture different stories and experiences. I’m looking for different standpoints, right? you might be a practitioner, or you might be balancing for instance, a social work perspective to helping and including indigenous knowledge and indigenous helping in that. 

You might be a researcher, for instance. You might be from a different locale or a cultural experience or group. Those are all kind of factoring in. And it’s also about convenience. , I’m doing this alongside my everyday work. If I happen to be in a part of the province where I know somebody lives, I’ll try to make that connection. One of the essential aspects of this is to have that face to face. And so it’s a blend. The ideal for me is to do an in-person recording if that’s possible. But I’ve also done them remotely, remote recordings through Riverside, by way of example, if I know it’s going to be Riverside, I make it essential that I meet with them in person beforehand. 

The more challenging part is to build that relationship because there needs to be some work invested into that. I’m not saying a whole lot, but there needs to be some kind of connection because as human beings, we interact face to face and communicate in those kinds of ways. So the initial first grouping was a bit of a balance between those who had somewhat known or had known of me. I had met them before and in some instances that might not have been the case, but it was mostly that scenario. They were comfortable with me.  

I also emphasized the spirit and intent, right? It’s about education and they …the guests on the podcast recognize the context in which things are, where indigenous peoples are not understood. There’s a lot of discrimination, a lot of conscious and unconscious bias in social interactions. There’s an exclusion of these ideas in the formal education. All Indigenous peoples are experts in these things. They know it. They know it from their inner essence and their being. They understand the potential that education can have in trying to address this. From my perspective, they see themselves as trying to change things, as am I. We both recognize that.  

I centralize education because with education, I’d like to humanize an understanding of traditional healers. I’ve been talking about indigenous issues for my entire teaching career. I’ve been mentoring. I’ve just passed 20 years of doing that now. And since the beginning, there’s this reaction towards anything indigenous. You could just say the word “indigenous,”–I’m going back 10, 15 years–and you can trigger a response by some people. You could trigger a physiological response just by mentioning “Native,” “First Nations,” “Inuit,” “Indigenous”, etc. I’ve always known that and I’ve experienced that in the classroom.  

When I speak about Indigenous healing, especially towards a group that has is trained in the sciences, for instance, there’s this instant reaction towards it with the assumption that it’s inherently unscientific, or it’s all made up. It has no place. It’s just this interesting cultural phenomenon or social phenomenon. If you look at it, if you use science to look at it, you could draw the conclusion that there is an essential inherent bias in understanding this because there’s assumptions based on that. Science is not supposed to be based on assumptions and bias.  

So, I thought that if people could hear the story of the person, hear their life experience, they could recognize that this is a human being that exists in this world, and they have experiences just like I do. And I have no right to assume that they’re inferior because of the socialization in which I come from in respect to indigenous knowledge and indigenous peoples. So that’s part of it. It’s about educating and even, I’ll just add, for indigenous peoples themselves. I see this as a new medium of communication. And it’s a consequence of the impact of a digital world in which we’re faced with. It’s really adapting to that. In times in the past, this knowledge would have been shared by way of storytelling that may have been on the land, it could have been around a table. I grew up at a time when there were very little TV channels. I like to say two-and-a-half channels because the third channel worked half the time. I spend most of the time outside in the community . In the community, I would just be around and in the process of just being around, I learned a lot. 

I learned a lot because I would be around stories, around people telling stories, around elders who would be telling stories, and I would just be part of the furniture in that sense. Those days are not here in the present. Maybe they’ll return in the future. So I see this as a new form of storytelling, a digital storytelling, right? And there’s some literature out there on it Jennifer Wemigwans has a book on it [A Digital Bundle: Protecting and Promoting Indigenous Culture Online, U Regina Press, 2018]. 

I see this as being part of that process, right? It serves a purpose for different audiences in a medium that is compatible with both of those sides, right? And I think that both sides are looking for something different. Those who are just curious about what this all means, for instance, from a non-Indigenous perspective. But from Indigenous perspective, there’s a built-in marketing because many of the people that I’ve spoken to are known. They’re known in the indigenous community, but they’re not known outside of it. That also relates back to your original question about inviting people. I know who these people are. We’re part of a community. 

We’re part of people who know somebody, right? We’re not so far removed in this area anyway. And I’m also focusing initially mostly on Northern Ontario, obviously because that’s where I work, but also because there’s a tendency to invest in creative works and knowledge production in places where capital is concentrated. And in the province of Ontario, it’s concentrated in southern Ontario. 

So you have this natural tendency, I suppose, within that framework to collect knowledge in those areas. In Northern Ontario, there’s little research in all aspects of research in itself . I think I have a responsibility to reflect and it also comes back to the social accountability mandate of the Northern Ontario School of Medicine University, which is to reflect the society in which it is located. And I tried to reflect the work that I do in the society in which I’m located. I’ve said quite a bit of things there. That’s kind of where things are at. 

I’m always recording and I don’t know how long this is going to go, but I’m going to take it as far as I can and continue this work because there’s a lot of important lives that are being lived out there that many of us have not learned about or heard about. 

JD: Right. Thank you for that wonderful answer. So I understand that, first of all, a lot of people in the community and second of all, all of your interviewees, as well as yourself, feel a responsibility to pass on knowledge. And this educational opportunity is a trigger for why they might accept to be recorded. I have two more questions. They’re “medicine” stories, in looking at some of them, I’m interested in hearing you tell us what you think “medicine” is or is about, because “medicine” is there to treat disease. We take medicine to get rid of disease. And “healing” is a very important word in your podcasts. What is the “medicine”? What is being healed? 

DM: I’m glad you asked that question. It brings to mind that I neglected to talk about something else. Traditional medicine or traditional healing is often stated as being holistic that’s maybe a common denominator in most of the definitions you come across or what people have to say. However, the stereotype is that it’s limited to plant medicines. It’s limited to this material consumption of something to relieve something, to have this particular outcome. And that’s a Western paradigm within healing in itself. 

 And I’ve heard this from healers that it’s more than that. Really that’s what I’m getting at. Really what they’re doing. This is also a form of indigenous pedagogy, which is a way of indigenous learning. And storytelling was that way of learning, of teaching and learning but there was also, obviously, observation that happened and you go about it and do what you need to do. But one element of it [medicine] is storytelling. 

I’ve read these historical accounts that indigenous peoples would tell stories all winter long. So this is the time of storytelling, a time of education. That’s the legacy. And often indigenous peoples will tell stories by way of an answer. This is what I try to teach in the classroom that when we have a placement at NOSM for students to go into an indigenous community for four weeks. I help them prepare for it, I tell them that you’re going to ask an elder a question. They’re going to tell you a story and in that story, they’re actually answering that question for you. And you may not know the answer to that question immediately, but it might come a time in the future when you recall that story and you make that connection. 

It’s a form of autonomous learning where the teacher or the elder or the storyteller tells the story and it’s up to the individual to the listener to “get it,” or not. And at some point in time they will. So, in essence, it’s a bit of an assessment like where are you at in terms of your knowledge and comprehension and understanding? I use that by way of an example because the stories that are being told are precisely about Indigenous healing and indigenous medicines in the sense that they’re a reflection upon the legacy of colonialism in Canada and the violence it is instilling on people of the past and the present and the impact that that has on people’s lives and how that translates into and manifests into these physiological outcomes that a biomedical lens can offer.  

But it also speaks to you from a biomedical standpoint; you could look at the impact of stress on health. You could look at childhood development. You could take all of these frameworks and apply them if you wish to do so. However, the way that it’s spoken about, it’s about It’s about trauma and healing and how that’s overcome. And often I will come across or and even know that that these seemingly abstract human experiences are actually medical or medicine for indigenous peoples. For instance, just learning more about teachings can offer healing for an individual who is yearning for that; maybe through the colonial process [it] was excluded. And it’s a void in their life. And they need it. They need that reason and purpose and identity and a sense of being and understanding. 

That relates to mental health and also physical health as well. They’re seeking an answer to their situation. And this is helpful for them. It’s also, I like to say, not the only solution, but it’s part of the answer, right? So obviously, meeting in person with someone is the best possible outcome. But it’s maybe a gateway towards that, ideally that it offers an opportunity for those to reach out to others. 

It’s also about them telling us about what they see it being. And again, it’s from different perspectives, right? You might have a researcher who’s chatting about what this means. It might be an indigenous-physician guest who talks about finding a way to include. It could be an elder. Knowledge is a form of wisdom, and some of that relates to a healing wisdom And it could be a practitioner or it could be a helper. It could even be about human relationships. You could translate some of this into a social determinants of health framework. 

So there’s various ways of interpreting, but it’s much like the story of the artwork that I shared that is the logo. It allows for the listener to draw the knowledge that they need or the teaching that they need, at that moment in time, at the level that they’re at, on their own terms. There’s nothing here is being imposed on anyone. When I’m asking the questions, I’m simultaneously processing what the listener may be thinking. And I deliberately do not reveal too much of the details, for instance, and I leave it up to the listener to figure that part out. There is in some part of responsibility but I’m not doing it for the person, and for instance, someone might be talking about the meaning of ceremony in their life. And I don’t go too deep. I just kind of touch upon the surface and it’s up to the listener to dig deeper if they need to. Right. This is what I’m talking about here in terms of this non-hierarchical way of learning this indigenous pedagogy, where there’s responsibility that is understood to exist with the person who seeks to learn. 

 And the teacher, or the one who’s telling the story, is not imposing things in part somewhat seemingly abstract, but is directly saying what needs to be said. And giving that option to the listener: this is what I’m telling you. If you don’t understand what I’m saying to you, it means you have more work to do. 

JD: Yes. 

DM: If you do understand what I’m saying to you, then you have a choice to take something from this if you would like. You don’t need to do so. And that is it. 

JD: That’s very intriguing because it is a different way of conceiving of medicine and also of healing. And I got the message early on in looking at the podcasts that the disease we’re healing is collective, held in our society, a historical legacy in a sense. The last question I want to ask you is about “stories” themselves as a form of knowledge. You’ve made it quite clear that it’s a way of answering and giving information among First Nations people. It’s a traditional way of understanding. But you’ve got me thinking, since I’ve been looking at your podcasts, that medicine does that too, in the sense that we take a history of every patient and we’re not supposed to impose too much, just as you suggest [in your work], but we curate those histories. And the other way that storytelling is a form of knowledge in medicine is the case of the “case histories,” which go back to antiquity. In the sense that we build a disease concept from multiple case histories of people who’ve had similar symptoms or similar experiences. And so for the last question, I want you to talk about storytelling as a form of knowledge. 

DM: Okay, … Let me situate that with Anishinaabe understanding of things. There are two forms of stories. They’re one form of storytelling is the tabatacamowin, which is stories of the past of events that have occurred. And there are sacred stories. And that is referred to as atiso’kanak. 

The difference between those two? Well, “sacred” speaks for itself, they’re mythic, sacred. One of those stories is alive and that’s atiso’kanak. And those are sacred stories. We don’t really engage upon sacred stories in Indigenous Medicine Stories, but we do focus on tabatacamowin, those stories of lives lived. I just wanted to kind of situate that. Those are two forms of storytelling.  

 I think to engage with your answer, at the start I see commonality in humanity, and even commonality in intellectual paradigms. It’s almost as though we’ve been conditioned to be in opposition. In many ways, we’re still tribal peoples at our core and we’re the scientists and you can interpret this as being a “story,” but we’re going to call this a “case history” and we’re going to call it this. And it’s not going to be that, but as you’ve described, you’re, you’re talking about something that’s very similar. And some of this may be indigestible to some and incompatible, but at some point in time, maybe that might not be the case, but that’s how I approach this. I see commonality.  

I often talk about narrative medicine, you’ll be familiar with that, on how that’s kind of framed as this academic understanding of what you described: this way of telling our stories to the physician or even maybe to the patient sometimes. And I bring in storywork. And this is when I talk about this academically, like I’m doing now. Jo-ann Archibald, a Canadian academic from BC, indigenous Canadian academic, writes about “storywork” and a way of teaching [Indigenous Storywork: Educating the Heart, Mind, Body, and Spirit, UBC Press, 2008]. But it really comes down to the inner essence of this history of indigenous learning in itself, right? And I just described that atiso’kanak.and tabatacamowin and how , stories have always been part of things, right? 

I like to tell this story about how I was doing this project with the First Nations Information Governance Center on Indigenous perspectives of poverty. And I was speaking to a Mi’kmaq and this is in the east of Canada, a Mi’kmaq, I’ll say, knowledge holder, academic. I asked him six questions and he told me six stories, and the stories were over two hours long! And it was after about maybe 90 minutes when he paused and he confessed. He goes, “You know, I don’t know if I’m answering your question and I don’t know if you’re understanding what I’m saying.” 

And I said, “I understand precisely what you’re saying. Keep on going.” When he came to the end in that research project, I just felt that at a loss because I could only capture maybe a minute or two of nearly two hours of very, very interesting stories that he was telling me that were just vibrant and alive. I could just feel and sense the detail of what he was talking about. Really, that’s what this is all about. It’s about demonstrating the utility of indigenous storytelling in educating because that’s what these are all about. And an elder or storyteller or, just an elder or, most will tell you a story anyway, right? They’ll just jump in the story and It’s just how it is, right? And it’s almost like this natural inclination of how to answer your question, because I think it makes it more interesting. When I hear stories about people’s lives and about experiences that they’ve had, it’s more interesting. I think you can remember it in much more detail.  

I’ll just give you another example. I was going down this body of water close to where I live, where I hadn’t gone to before when I was new to boating. And I was speaking to an experienced person in the community who knew the waters very well. And he was telling me by way of story about how to navigate those waters. And it was almost like generating a mental map in my mind through the anticipated experience that I would go through in order to really kind of paint a picture of a map of where to go. And he also did that with even hunting, where he would tell me, okay, you got to go here and then he would kind of generate this portrait of this place. And as I was going through those experiences I could hear the voice in my mind describing what I was seeing as I was doing it. It was kind of like an original kind of a GPS kind of experience.  

And I’ll just give you one more example of this. When I was early in my career, I was teaching indigenous studies at the University of Sudbury, which was formerly a federated University of Laurentian University in Sudbury Northeastern Ontario and I had invited an elder to come speak to the class and I thought they were learning all of these things. I was teaching a course on Indigenous tradition, culture, and spirituality. So I thought maybe I’ll invite an elder to the class. And the elder came in and I just gave a general idea, a general orientation to what the content was about. I didn’t impose what they should talk about, but I just offered that’s a useful direction to go. And over the course of an hour, the elder was telling stories about life and life stages and all of these things. And I found it fascinating. I was just captivated myself while sitting in the audience with the students. I just took a little pause and I looked around and I realized that some had no idea what was going on. 

They were expecting this structured lesson plan with learning outcomes and content that would correlate some way to those learning outcomes and then, if they were being evaluated, there would be some kind of assessment associated with that. And I just came to the realization that there is something different here and there’s something worthwhile to consider. After the next class, I had basically deconstructed things for students to explain that this is how things happen. I began to learn that this is something that I needed to explain because it’s just something that just happens in its natural form. 

Also, and as this relates to myself here, I didn’t immediately understand the meaning of all of what that elder had stated that day. I understood some or most of it. And it was probably about maybe five to seven years after the fact that I remembered that story and I still remember the story and this story, this is like 15 years ago, right? So this maybe speaks to the power of story in itself. It was five or seven years after that point in time that it was like a Eureka! moment that this is what that elder was telling me. I didn’t understand it at that time, but now I understand it. And I remember that story and I remember what they were trying to tell me and they were actually doing something that they thought was important for young people to know. 

At that time, I was young myself. Stories are very powerful. And I think it’s the ideal medium to transmit knowledge and to even translate knowledge in this essence and if the listener does not yet know what’s going on, then at some point in time, possibly they will. And they may return back to the story and find something new. 

And that’s the neat thing about learning. Sometimes you return back to a book you read 10 years ago and you find something new to learn and understand about it. So the same is the case with Indigenous medicine stories. 

JD: That’s wonderful. Darrel. Miigwech! Thank you so much. 

DM: Thank you for having me. And I look forward to sharing more Indigenous Medicine Stories with all of those who are interested in hearing them. 

Darrel Manitowabi is an associate professor in the Human Sciences Division at the Northern Ontario School of Medicine (NOSM), Sudbury, Ontario. He is a citizen of the Wiikwemkoong Unceded Territory, and he currently resides in the Whitefish River First Nation. He is an applied, medical and Indigenous anthropologist with research interests in Nishnaabe ethnohistory and Indigenous gambling, Indigenous social determinants of health, Indigenous healing, Indigenous-state relations and Indigenous self-determination. His research and publications examine how the historical legacy of, and contemporary expressions of colonialism impact the health and wellbeing of First Nations communities. Furthermore, his research examines how First Nations communities are active agents in decolonizing the Indigenous-state relationship through centring Indigenous perspectives in health, education, and governance.

Indigenous Medicine Stories Podcast

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 

01.12.26 692

From Tigers to Otaku

09.16.25 1544

The Happiest Couple

07.28.25 1296

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

05.13.25 1877

One Patient, Two Systems 

02.24.25 2540