On the one hand, if the doctor is physically unable to treat, then he is not responsible for withholding treatment. On the other hand, by being rendered professionally helpless, perhaps he is being punished for not taking a moral stance against his patient. This interpretation seems to have validity because the last line recalls Psalm 137, which warns, “If I forget thee O Jerusalem, let my right hand forget her cunning.” 

For drawing attention to the biblical reference, I am grateful to Dr. Danielle Ofri (clinical professor) and Lara DeLong (Class of 2001), both at NYU School of Medicine. Dannie Abse (1923-2014) was a practicing physician and poet. 

Reading by Dannie Abse

Case History
‘Most Welshmen are worthless,
an inferior breed, doctor.’
He did not know I was Welsh.
Then he praised the architects
of the German death-camps–
did not know I was a Jew.
He called liberals, ‘White blacks’,
and continued to invent curses.

When I palpated his liver
I felt the soft liver of Goering;
when I lifted my stethoscope
I heard the heartbeats of Himmler;
when I read his encephalograph
I thought, ‘Sieg heil, mein Fuhrer.’

In the clinic’s dispensary
red berry of black bryony,
cowbane, deadly nightshade, deathcap.
Yet I prescribed for him
as if he were my brother.

Later that night I must have slept
on my arm: momentarily
my right hand lost its cunning.

Commentary

“Sometimes it’s very difficult to like some patients. Patients imagine that they’re always likable, but in fact there are some one has great difficulty with, I think. And indeed there was one patient that bugged me so sufficiently that I wrote two poems about him.”

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.
Web image created by Medhum.org

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 

01.12.26 930

From Tigers to Otaku

09.16.25 1826

The Happiest Couple

07.28.25 1544

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

05.13.25 2128

One Patient, Two Systems 

02.24.25 2820

This eloquent statement against the madness of war is the first novel in a trilogy that includes The Eye in the Door (1993) and finally The Ghost Road (1995), which was awarded the Booker prize. The story is closely based on the publications and annotated literary papers of three real men who met at Craiglockhart in 1917: psychiatrist W.H.R. Rivers (1864-1922) and two poets: Siegfried Sassoon (1886-1967) and Wilfred Owen (1893-1918). Owen wrote some of the most moving war poetry and the knowledge that he would be killed in action at age 25 simply adds to the poignant sense of futility.  

Pat Barker (b. 1943) probed the tenacious role of class within the military hierarchy, while the society, which the military purports to defend, is rapidly being transformed by the converging lives of domestic servants and aristocrats. Her descriptions are powerful: the yellow skin of women who work in the munitions factory; the surgeon who can no longer bear the sight of blood; the young soldier who cannot eat because his nose and mouth had once been filled with rotting flesh when he was hoist by a grenade into the decomposing belly of a dead German. Rivers helps the men to recall and to understand the origins of their ailments by gentle, patient conversation–a treatment that he described in Lancet, 2 Feb 1918. 

Regeneration
Pat Barker
London: Viking Press
New York: Plume
1991, 256 pages)

From the Vault: In these times, certain works of literature seem to be as relevant to us now as when they were published — possibly more relevant than the times that they depict. From the vault of the now closed Literature, Arts and Medicine Database, we will pluck a few items for their power and timeliness. 

Web image by  National Library of Medicine

The Eye in the Door, the second in the trilogy, turns its attention to the Home Front, and more specifically describes the rampant paranoia during the war, as the government targets two groups:  homosexuals and “conchies,” or conscientious objectors.  While it too is tethered to historical fact, it is more of a fictional narrative concentrating on the state-sponsored witch-hunt, refracted through the story of Billy Prior, a patient of Dr. Rivers.  Billy is bisexual; he also grew up with childhood friends who became pacifists and objectors, and who may or may not have been involved in a plot to assassinate the Prime Minister, and so he moves in both of these marginalized and persecuted worlds.  He also has fallen in love with a woman whom he wants to marry.  During his ongoing treatment of Billy, Rivers confronts his own repressed childhood memories.   

The Regeneration Trilogy has much to recommend it in considering works of literature in the area of medical humanities.  First—and obviously—it is about the psychological damage suffered by young men pressed into military service during wartime, and the way in which medicine approaches their resultant illness with the tools it has at hand.  Each one of these soldiers has a story, each one has a trauma, and there are no pharmacological options. Much like Freud (a contemporary whose work was well-known to him), Rivers felt that the way to treat the shell-shocked soldiers was a “talking cure,” making the traumatic events unrepressed and having the patients recognize and address them.  The stories of the soldiers’ treatments are engaging, Rivers’ warmth and compassion for his charges is unmistakable, and the nature of physician-patient interaction during treatment is explored.   

Barker also poses questions about gender; more specifically, about the nature of manhood and the role of women in a male-dominated society turned upside down by a cataclysm.  Being a man in England during the war means being in uniform and preferably fighting in France; the conchies and the gay men are seen by many, including many women, as being “less than” men, and in their otherness, as subversive.  Women, for their part, have had to step up and assume the roles in the workforce that men have vacated to go off to fight.   It is supposedly the love of their fellow men that allows the soldiers to fight as a unit, to want to enlist and to want to re-up after they are wounded, and this comradeship is trumpeted by those in command.  But it is crucial that everyone understand that this must be the right kind of love; the wrong kind of love is ferreted out and made example of. 

There are many paradoxes, and many instances of doubling or of opposites, in the novels.  Rivers wants to cure his patients, although curing them will render them fit to be sent back to combat and likely be killed.  Several bisexual men lead bifurcated lives.  And underlying all of it is a society rigidly divided along class lines, with the WC’s—the working classes—distinguished not only by their living and working conditions but also by the idiomatic speech put into their mouths by the author.   The war may be in some ways a great “we’re all in this together” moment, but it can’t erase class distinctions.   

It is worth noting that Barker’s style can range over to the gritty and realistic, as well as the graphic, whether describing the events occurring on a battlefield in Picardy or in a bedroom (or back alley) in London. The writing style is crisp, and the narrative moves along nicely.  The author’s characterizations are on point, especially William Rivers and Billy Prior.  Barker has a great feel for language, although some of the words and expressions several of the characters use are distinctly British and may be unfamiliar to American ears.  She conveys an England—or at least, a segment of England—tired of war, tired of being bombed, often living hand to mouth in cold water flats with faded wallpaper and trying gamely to carry on despite being ground down. 

And underlying it all, The Great War—its idealization, its senselessness.  The three volumes of this trilogy are beautifully written, hold the attention, and move quickly, and its relatively spare language has a lot to say. 

The Eye in the Door
Pat Barker 
Dutton: 1994, 288 pages 

Photo of Chester from  The Cleveland Museum of Art