Hugh Ip: Reverse culture shock

Hugh IpI got out of the lift on the sixth floor of S block.  I asked a nurse in Cantonese, “is this the respiratory medicine clinic?”  “That’s right; you’re an overseas elective student aren’t you?”  “Yes.”  “Sit here and wait for the doctor.”

The doctors had not arrived after 20 minutes, so I plucked up the courage to speak to the nurse again: “If you don’t mind me asking, how did you know I’m not a local student?””  “I could tell at first glance that you’re from abroad!”

She did not give me a satisfactory answer; I was perplexed since I speak fluent Cantonese without an accent.  In fact I grew up in Hong Kong; I only left six years ago to attend medical school in London.  So I was eager to find out what it would have been like if I stayed, and what I would need to adjust if I were to return.  And here I am, on my elective.

A city in hyper-drive

My first observation was how the nurses navigated the ward with superhuman speed.  I did not think it possible for a nurse to take care of so many beds competently and efficiently, while assisting the medical officer on her morning round!  This may be the rationale for their wearing of running shoes, as did the interns.  The interns were so busy that I barely saw them.  In comparison, house officers in London often have spare moments to teach medical students.  I think that the 48-hour week imposed by the European Working Time Directive makes a significant difference.  A Hong Kong intern told me that he works more than 80 hours a week!

Queen Mary Hospital, Hong KongI have appreciated the time and space in London to think and mature.  But can I still survive the time and space pressures of Hong Kong?  The city is rightly proud of its efficiency, manifested even in its hospital design.  At Queen Mary Hospital, clinic rooms only have three walls.  Instead of a back wall, a corridor at the rear connects around ten adjoining clinic rooms, so nurses can move swiftly from one to another.  On the wards, beds are more tightly packed than I am used to, probably due to the public sector’s high patient load.  Doctors are adept at examining from the patient’s left, since it is often impossible to access the right side of the bed.

Though doctors can compensate with examination technique when beds are closely packed, confidentiality is more difficult to maintain.  One method is to speak to other healthcare professionals in English.  My grandpa told me about his hospital experiences, when the doctors assumed he could not understand their discussion, as most patients are more fluent in Cantonese and Mandarin.  A second attempt at maintaining confidentiality (and efficiency) is the extensive use of abbreviations.  “This patient had an EMA (Extra-Marital Affair).”  “Unfortunately this bed DMA’ed (Discharge against Medical Advice).”  “The problem is AROU (Acute Retention of Urine).”  Nevertheless, some abbreviations are widely understood by patients: “this is the HIV patient”.

The burden of experience

doctors in Hong KongQueen Mary Hospital staff are required to wear surgical facemasks in all clinical areas to minimise the risk of H1N1 swine flu transmission.  The last time I had a mask on for so long was during the 2003 SARS outbreak.  It took a heavy toll on Hong Kong, preparing it well for this new epidemic.  The medical culture of London hospitals is more laid back in comparison.  At least for now, masks are only required when approaching patients with suspected swine flu.

“You need to lose some weight!” said the doctor in Cantonese during a ward round.  Another patient chipped in from three beds away, “the doctor’s right, he eats so much at mealtimes!”  Food plays a prominent role in Chinese culture, permeating into medical culture.  In London, I was taught to ask patients if they noticed “black tarry stools”.  Hong Kong medical students ask patients if they notice “black sesame soup stools”.  Black sesame soup is one of the city’s favourite desserts!  To assess total calorific intake, dieticians specifically ask if patients eat the ingredients of Chinese soups.  These can be very substantial, including pork, chicken, fish, pumpkin, and apple.  An important part of an occupational therapist’s assessment is to determine how well the patient can use a pair of chopsticks.

I am familiar with London’s hospital canteens.  The options are usually: a salad bar, sandwiches, a hot vegetarian dish, two meat options accompanied with potato or pasta, and a hot dessert.  So I was bedazzled by the sheer range of options in Queen Mary Hospital.  I could choose from over 20 toppings for my portion of rice, as well as various noodle dishes!

As I heartily yet discreetly gave thanks to God for my lunch, I noticed numerous bowed heads around me in the staff eating area.  Healthcare assistants, doctors, medical students, and nurses; they were all saying grace.  It is a much rarer sight in London from my experience.  I met a Hong Kong medical student who estimated that one third of his class were Christians.  The conviction and boldness of staff and patients in practising their faith in daily life inspired me greatly.  Two cancer patients, of their own accord, told me about believing in Jesus because of their disease experience.

Family ties

I encountered a patient who was very disappointed that his brother had not visited yet.  The concept of family is so important in Chinese culture, strongly affirmed in Confucian teachings.  During visiting hours I found it difficult getting around the ward, because there were usually so many relatives around.  They would often bring home-cooked food in thermos flasks.  Yet I saw “OAHR” written in many sets of notes on the general medical ward, standing for “Old Age Home Resident”.  Perhaps the patients were too ill to stay with family.

Spending a rare few weeks at home reminded me how far away London is from my family.  Most memorable were the noisy conversations at the cluttered dinner table, which I took for granted as a school child.  I am grateful to see my grandparents enjoying independent and fruitful lives.  All credit to the doctors who are expertly managing their cardiac, endocrine, neurological, rheumatological, and ophthalmic problems!

I cherished this opportunity to understand the healthcare needs and services in Hong Kong, as I hope to serve my people one day.  I have a year of medical school left, then straight into the two year UK foundation programme (internship).  To practise in Hong Kong, I would also need to take its licensing exam (the pass rate for part one was 8% last year!).  When I return, I will exchange my short white coat for a long one to blend in.  I can make plans, but only God knows what the future holds.  I will take one step at a time, continuing to give my best in my medical studies once the plane lands at Heathrow airport.

Acknowledgments: I thank Dr  Jamie Lam, Colleen McGregor, Noorulhuda Jawad, and Louise Ho for their comments on an earlier draft.

Hugh Ip is a final year medical student at Imperial College London. He is a former Student BMJ editor ( and Nucleus editor (