Taiwan Bypass: Heartwork in Kaohsiung 1

Taiwan Bypass: Heartwork in Kaohsiung By David Alexander

An Interview with Bob and Mary Ann Walter, conducted on December 29th, 2006, six weeks
after Bob’s triple bypass surgery.

What brought you to Taiwan, and how long have you been here?
Bob: In 1993 we were contracted to work at Morrison Academy. I started out teaching third
grade in Taipei but the next year became the principal in Kaohsiung. We came to Taiwan on a
two-year contract. Two years have stretched to fourteen.

Did you have heart trouble when you arrived here?

Bob: I was 48 when we arrived and had problems with cholesterol and not being able to keep
my weight down. That led to some monitoring. A more fundamental issue was that my side of
the family had some serious medical issues, namely coronary heart disease, high cholesterol,
diabetes and cancer.

When did you begin being monitored in Taiwan, and where did you get go?
Bob: As is prudent for anyone my age, I was having regular checkups with a family physician,
Dr. Ho (何鐵樑) in Kaohsiung. He wanted to put me on a cholesterol-reducing drug but I
preferred to use alternative means including a better diet and more exercise.

Were you being followed by doctors in the USA at the same time?
Bob: On a trip to North America in 2004 Mary Ann and I took advantage of a medical screening
service and had heart scans. These were recorded onto a CDROM that we brought back to
Taiwan with us. Mine indicated that the alternatives to medication hadn't helped as much as I
needed them to. I'd always thought that since I wasn't having “cardiac symptoms” I didn't have
to be very concerned, but we found out that 34% of fatal heart attacks in the USA occur to
people who had no prior symptoms. As we consulted with Dr. Ho (何鐵樑), he told us that the
brightest and sharpest cardiology people in Southern Taiwan were all at Chang Gung Memorial
Hospital.

What precipitated your having to get bypass surgery?

Bob: We arranged an appointment with a cardiologist at Chang Gung, Dr. Fu (傅懋洋). When
we met him he asked, “What are your symptoms?” When I said there were none he asked,
“Well, why are you here?” After he looked at the result of the heart scan he ordered a resting
EKG and a treadmill test. They clearly showed that a couple of arteries were partially blocked.
In the spring of 2006 we decided to proceed with a three-dimensional MRI heart scan
that had recently become available in Taiwan. It confirmed Dr. Fu’s concern. The next step,
taken late in September, was an angiogram. They inserted a scope into my arm, up through my
shoulder and all the way to my heart. They literally looked at the arteries in question and were
able to eliminate some strategies and decide on the eventual plan for bypass surgery. During the
procedure the doctors, though they could have done all of their consulting in Chinese, used
English to include me. They even moved the table so I could see the video monitors, showing
me where the blockages were. I was involved in the discussion. They invited my questions
while I was right there on the table.
They eliminated the options of balloon angioplasty or the insertion of stents. These had
 Taiwan Bypass: Heartwork in Kaohsiung 2
to be considered because the National Health Insurance Bureau only pays for bypass surgery if
“lesser” methods are not viable. In my case the extent and locations of the blockages ruled
things out. This decision was an answer to our prayers for clarity. I wasn't so eager to have a
bypass operation as I was to be certain about what to do. Dr. Fu and Dr. Li (李芳艷), the
bypass surgeon, were able to look at the angiogram results and say, “This is what we've got to
do, Bob.”

Was going home to the USA an option? If so, why didn't you choose it?
Mary Ann: Returning was never really an option because after 14 years in Taiwan we had no
established family doctor in the USA. They have all been absorbed into Health Maintenance
Organizations (HMO’s). While it may have been possible, it would have been extremely
expensive.

What was it about Chang Gung and the doctors that led you to opt for local treatment?
Bob: We had read Complications: A Surgeon's Notes on an Imperfect Science by Atul
Gawande. He recommends going to a hospital that performs a significant number of similar
operations because they are experienced in the latest techniques and procedures. We asked
questions of Dr. Fu, Dr. Li and the angiogram specialist, Dr. Wu (吳炯仁) and learned that at
Chung Gung's Kaohsiung Medical Center they perform between 200-300 CABG (Coronary
Artery Bypass Grafting) operations a year.

How did you deal with the language issue?

Bob: Because we've never had significant time to learn Chinese, our language skills are very
limited. The specialists, because they had worked and studied at places like the Mayo Clinic, the
Cleveland Clinic and Harvard Medical School in the USA, have fantastic English. We did rely
on a colleague at Morrison Academy staff to make appointments for us because the hospital’s
clerical staff have limited English. But once we were with the doctors, only English was
spoken.
When I was an in-patient the doctors spoke only English. They were very clear. They
also assigned a specific person on the ward to be available if we had any questions. Most of the
nurses speak only a little bit of English, but there was always somebody on nursing duty with
fairly extensive understanding and communication skills. We had chosen to stay in Kaohsiung
rather than going up to an “eminent surgeon” in Taipei because we knew that we would need a
lot of support from friends. Hospital stays can be very demanding if you're the only one
supplying support.

Mary Ann: When Bob was in ICU following his bypass and afterwards, it was good to have
somebody with Chinese language skills to help me out because staff easily missed little details
when attempting to explain procedures to me. We have a dear Chinese friend whose English
name is Ashley. She helped out during the ICU stage, and other friends who speak either
Mandarin or Taiwanese came to help us after Bob was moved from ICU to a regular room. We
needed them because the questions that we had for the nurses were not always clearly
understood. It is also good to have somebody with good language ability check you in and out
of the hospital. And somebody with a Taiwan household registration needs to sign for you. You
can't be admitted with just your Alien Resident Certificate; they need assurance that the bill will
be paid.
 Taiwan Bypass: Heartwork in Kaohsiung 3
Mary Ann, What was your hospital experience like?
Mary Ann: We opted for a private room after surgery so we wouldn't have some of the
extraneous distractions from being in a ward. Whenever we rang our bell they were there to
meet our needs. They were careful about giving medications, telling us when to take them and
so forth. We couldn't have asked for better care. If I wasn't there, we always had a work
colleague or a friend from church present to help. Of course, the private room came with a cost
– around NT$3000 per day extra.

Mary Ann, did you feel respected by the medical staff?

Mary Ann: The hospital staff and doctors were very accommodating, probably because we were
foreigners. I felt respected by the medical staff. It may be because we had done some research
and were knowledgeable about the situation. With Dr. Li, (李芳艷) the surgeon, we would say
“Sorry, we have a question...” and apologize. He'd say, “Don't apologize, you're the patient;
you're the VIP. We do everything we can to make you comfortable.”
While Bob was in ICU, although visiting hours were normally limited to three per day,
they let us stay with him the entire day. I think it was because they were afraid they wouldn't be
able to communicate with him and needed somebody there who could.

What resources did you have to take care of your other needs? Mary
Ann: The first few days after surgery, Bob wasn't fully aware of things and needed someone
near him almost the entire time. I stayed at the hospital, and friends kept us company. I think
that it would be very difficult without friends or colleagues to help with the care. Downstairs at
Chang Gung Hospital there is almost every kind of food service that you'd want. Beyond that,
we were even able to have a beautician come up to the room to give a Bob a hair wash and
shave.

Have you "run the numbers", comparing the price in the USA to the cost in Taiwan?
Bob: We've compared costs using US dollars. The total cost of the surgery here in Taiwan
came to about US$10,000. That same surgery would cost US$75,000 in the United States.
Because we are covered by Taiwan's Bureau of National Health Insurance we paid only
US$2,000 ourselves, and US$800 of that was because we chose a private room. We estimated
that if we had been covered by a typical insurance program in the USA and had the surgery
there we would have had to pay US$15,000 of our own. That's a factor of 7 to 1. Cost wise, it's
pretty hard to argue with that.

How are you feeling now, and what do you expect in the next few months?
Bob: Outcome is a matter of perception. I think you never know until you experience
something whether your estimate of how you'll feel in 2 weeks, 6 weeks, 10 weeks, whatever, is
correct. Six weeks have elapsed since my surgery (in mid-November) and I still feel some
tightness in my chest. I am getting used to the healing process but the doctor thinks I'm right on
target. I'm working myself back into an exercise routine and am starting to build up my
endurance. Hopefully by March, I'm going to be able to do some pretty rigorous exercise.

What factors contributed to your good outcome?

Mary Ann: Bob’s surgery took a lot longer than we had anticipated. It was only later that we
learned that Dr. Li had used a recently developed procedure called OPCAB (Off-Pump
Coronary Artery Bypass). The chest doesn't have to be opened up as far and the heart continues
 Taiwan Bypass: Heartwork in Kaohsiung 4
beating while the bypass grafts are sewn in place. This procedure takes longer but it usually
reduces the bleeding and need for blood transfusions along with other possible complications.
We were very happy with their competence.

Bob: Faith is also an important factor, our faith and that of the friends who supported us. God
had answered our prayers for clarity and a course of quality treatment was available, so we went
ahead. We were both confident that, even should something have gone drastically wrong, we
were and we remain totally in the hands of a loving and caring God. With that kind of
confidence and the support of loving, believing communities both at Morrison Academy and
Kaohsiung Community Church, we did not hesitate.

What word do you have for residents of Southern Taiwan who may have heart conditions?
Bob: I would recommend this hospital and these doctors to other expatriates, and I would say
without any reservation that if a person has cardiac issues, clearly our experience tells us that
Chang Gung Hospital, its doctors and other staff are well qualified, accommodating and
professional. I don't see how we would have gotten any better service or access to specialists
than we received, so we don't have any reservations at all. I would not hesitate to go back and
have it done again.