"The compassion emanating from a feeble Buddhist nun made it difficult for us young physicians to turn down her invitation to join her to serve. Because we shared the same ideals, we felt we had found the right place to put our compassion to good use. That’s how we embarked on our journey in Tzu Chi."
Those words were delivered by Dr. Hann-Chrong Kuo (郭漢崇) in 1988, at a ceremony marking the second anniversary of Hualien Tzu Chi Hospital. Kuo and about a dozen other young physicians had just left their careers at the venerable and prominent National Taiwan University Hospital (NTU Hospital) in the heart of Taipei to join the fledging Hualien Tzu Chi Hospital, located in the remote city of Hualien on the relatively undeveloped eastern coast of Taiwan.
Like the others in his cohort, Kuo had stepped upon the stage to explain to the gathered audience why he had chosen an uncertain future in Hualien over a tried and true career path in Taipei. His decision was a choice that few doctors had been willing to make. Not surprisingly, Hualien Tzu Chi Hospital had experienced a severe shortage of medical professionals in nearly all of its medical departments. All of them, including the Department of Urology, relied on the services of attending and resident physicians from NTU Hospital.
Kuo pledged that he would sign a 30-year employment contract with the Tzu Chi hospital and help relieve the personnel shortage in the Department of Urology so it could serve its patients without delay.
That was 28 years ago, and a lot has changed. Over that time, it has grown from a chronically understaffed department to one of the preeminent urological research and treatment centers in Asia. Physicians from far and wide, even from other countries, flock to the hospital to receive training.
This photo of Dr. Hann-Chorng Kuo (left) and Master Cheng Yen hangs on a wall in his office to remind Kuo not to deviate from his initial commitment to serve patients. The efforts of Kuo and his team over the past 28 years have made the Department of Urology at Hualien Tzu Chi Hospital a major research and treatment center and a magnet for young physicians to receive training. COURTEST HANN-CHORNG KUO
In the old days in Taiwan, urology was not a popular specialty choice among young physicians, who favored internal medicine, surgery, OB/Gyn, and pediatrics. Doctors who ended up in other disciplines were usually there because their medical school grades were not high enough, as was the case with Kuo. Knowing that at best he would only be put on the waiting list for those hot specialties, he opted for a career in urology instead.
Having made his choice, he went at it wholeheartedly. He bought a complete three-volume set of thick urology textbooks, read them over and over again, and made careful notes.
After his residency at NTU Hospital had ended, he and a few other doctors volunteered to be stationed at Hofuf Hospital in rural Saudi Arabia. Doctors who volunteered to serve there for two years would be promoted directly to attending physicians when they returned to Taiwan.
Physicians from many countries worked at Hofuf, so it seemed like a mini United Nations. However, a spirit of mutual support was lacking. When physicians there saw others mess up, they would just look on instead of offering a helping hand—perhaps because they wanted to make themselves look good. Working in such an unfriendly environment, Kuo learned to perform each and every operation with the utmost care and caution, as if he were walking on thin ice.
After his stint at Hofuf, he returned to NTU Hospital, received the promised promotion, and became an attending physician.
One day two years later, Dr. Yao-Jen Chang
(張耀仁), Kuo’s college roommate for six years, invited him to consider moonlighting at the newly opened Hualien Tzu Chi Hospital to support its urology medicine. No hospital in the greater Hualien area at the time had a urology department, so patients had little access to urologists. Patients needing such specialists either put off seeing the doctor until they could not stand the illness any more, or they sought help from other physicians like internists or surgeons. If they could afford it they went to Taipei, where such services were abundant.
Chang’s suggestion led Kuo to start practicing urology part-time in the Hualien hospital. That was in October 1986. Kuo’s first operation there was on a patient with bladder stones. Kuo continued for two years to hold an outpatient clinic in Hualien one day a week. During that time, he formed deep bonds with his Hualien patients.
Kuo figured that in Taipei he would be just one of many urologists, and hardly anyone would be inconvenienced if his services were unavailable. But it was an entirely different story in Hualien, a place sorely in need of medical resources. He contemplated moving to Hualien to work full time. His colleagues urged him on and his family supported him, so he chose not to pursue further study in the United States and instead joined the Tzu Chi Hospital. That was nearly 30 years ago, in 1988.
In this photo from two decades ago, Kuo conducts an ultrasound examination of a patient’s kidneys. COURTEST HANN-CHORNG KUO
The Department of Urology
Now that there was a full-time urologist on its staff, the hospital quickly purchased videourodynamic study equipment to more precisely diagnose and treat patients with urinary tract dysfunctions.
The hospital also bought high-caliber urological ultrasonography equipment worthy of the best medical centers. Using this equipment, the urological team at the hospital completed the first continent urinary diversion surgery in eastern Taiwan. The team also used it to monitor physiological metrics in women with urinary incontinence, and on the strength of the collected data they published several papers.
Kuo and his team plugged along. By the fifth anniversary of the hospital, three years after Kuo’s arrival, they had logged more than a thousand urological operations, some of which were sufficiently difficult that only a few select medical centers in Taiwan could have accomplished them. What is particularly worth mentioning was the ileal neobladder surgery the team offered. This procedure brought untold blessings to patients who otherwise would have needed to live with urine drainage bags attached to them.
“I was probably the second or third surgeon in Taiwan to perform this surgery,” Kuo commented, “which even today few surgeons perform. Many young surgeons dare not attempt it because their teachers don’t teach it.”
Kuo pointed out that doctors used to take a more conservative approach in treating bladder cancer and neurogenic bladder dysfunction. A typical surgeon might have removed the bladder, resected a segment of the small intestine, anastomosed the ureters to one end of the intestinal segment, then pulled the other end of the intestinal segment to form a stoma in the lower abdomen. An advantage of this conventional approach is a low risk of complications, but the big disadvantage is that the patient must forever live with a urine bag. This greatly degrades the patient’s quality of life. A person may shun social contact or become overly conscious of being in a closed space because he or she might worry about a leak or any noticeable odors.
Kuo had often pondered this problem while he was still an attending physician at NTU Hospital. Later in Hualien, he took the conventional surgical approach as detailed in literature and modified it with an eye to improving a patient’s quality of life. As in the conventional method, his modified version also utilizes a resected segment of the small intestine; but unlike the conventional approach, he executes a double-folding suture, making that small intestinal segment into a sac which he then sutures to the urethra.
Kuo’s modified surgery is difficult to perform and more time-consuming. It also requires extensive post-operative care. However, with all this extra effort, a patient can urinate normally without relying on a urine bag.
As can be expected, that benefit has turned out to be a huge draw for patients far and wide. Many patients have even traveled from Taipei—the most medically advanced city in Taiwan—to Hualien in order to obtain Kuo’s care and receive the benefit of his surgery.
Kuo arrives at his office every morning before seven to take care of mail and paperwork.
Pushing the envelope
Urological patients often suffer from discomfort or embarrassment that is beyond the understanding of people who have not experienced the same problems. Kuo gave an example to illustrate this. A successful businessman had had an operation for his prostate cancer. Though the surgery had successfully removed the cancer, he began to leak urine. The problem persisted for a year. Kuo thought hard about how to fix the problem, and he eventually decided to try urethral suspension surgery, a very advanced procedure at the time, which modified the bladder neck suspension surgery for females to suit the needs of male patients. It worked. The leak stopped for the patient the very next day after the surgery.
The patient was ecstatic. In tears, he thanked Kuo repeatedly for relieving him of the misery that had dogged him for a whole year. He had deeply despaired because of his urine leakage problem—it was even worse than having cancer. He had had to wear an adult diaper because of his condition, and that had led him to routinely turn down invitations from friends to go golfing or take walks. No amount of business success meant anything to him when he was unable to control his urination. But now all this wretchedness was a thing of the past. He felt that his world was once again filled with color.
Kuo is deeply convinced that “a physician must concern himself with not just curing an illness, but also improving the patient’s quality of life.”
In 2012, Hualien Tzu Chi Hospital established a Voiding Dysfunction Therapeutic Center, the first such center in Taiwan. The center combines under one roof treatment of and research on urodynamics, overactive bladder, bladder outlet obstruction, voiding dysfunction, urinary retention, etc.
The efforts of Kuo’s team have not gone unnoticed. Hualien Tzu Chi Hospital has been ranked among the top 30 in the world in urological research and the third in the quantity of diagnosis, treatment, and research on overactive bladder.
Kuo patiently answers a patient’s questions while on rounds with his colleagues.
Constant search for a better way
Kuo’s team has attracted patients from other countries as well.
An Australian man, John, about 40, had long suffered from a condition in which he felt the urge to urinate but could not actually do so. No doctor seemed to be able to help. Using his symptoms and the drug names that his doctors had prescribed for him as keywords, he searched medical journals and found some relevant papers. One researcher’s name popped up in almost all these papers: Hann-Chorng Kuo.
John traveled to Hualien and sought help from Kuo. Tests indicated that John’s bladder sphincters could not relax to allow urine to flow out. After ascertaining that the nerves and muscles that control urination were functioning normally in John, Kuo treated him with botulinum toxin (Botox). It did the trick, and John’s condition was cured.
Kuo explained that Botox had first been used to treat crossed eyes by relaxing eye muscles. He figured that if Botox could relax muscles, it could perhaps be effective in treating overactive bladder as well. Though he was pretty confident it would be a sound therapy, he nonetheless repeatedly checked out the side effects and potential risks. He also obtained permission from the government before using Botox on patients for whom traditional medical approaches had not worked.
The Department of Urology at Hualien Tzu Chi Hospital has had 58 research papers on Botox to its credit in the past 15 years, some of which have been cited by the American Urological Association as epitomes of therapies that have changed conventional ways of treating patients. Today, using Botox to treat urological conditions has become quite commonplace. The national health insurance system in Taiwan has even approved of such therapies as covered services. Many patients have benefited.
Reflecting on this experience, Kuo emphasized that research must originate out of a concern for patients. Only when it centers on their welfare will it become a meaningful project. Conducting research just for the sake of bumping up one’s paper count invariably results in empty talk that does patients no good. To Kuo, that amounts to a failure to do one’s duty as a physician. He always emphasizes this point to his students when he teaches.
Kuo demonstrates surgical techniques at a simulated surgery on a donated cadaver at Tzu Chi University.
A student once asked Kuo how he managed to conduct so many research projects while also fully occupied with his clinical responsibilities. “Here in Hualien, it takes me seven minutes to commute to my office and eight minutes to go home after work,” Kuo replied. “That’s 20 fewer days a year that I spend on commuting than you guys in Taipei.”
Apparently, Kuo puts those saved hours to productive use. He uses his time wisely and efficiently. He always arrives at his office before seven in the morning to take care of mail and office paperwork. He starts his rounds at 7:30 sharp with residents in tow. He chats warmly with patients—he has a knack for making people comfortable in his presence. To patients and their families, Kuo is personable and never stuck-up.
Jiang Yuan-hong (&؟$٨'؛), director of the Department of Urological Reconstructive Surgery and Endourology at Hualien Tzu Chi Hospital, has studied under Kuo for eight years now, since Jiang’s days as a resident. To this day, he feels that he has much to learn yet from Kuo’s ability to quickly earn the trust of his patients.
“He treats his patients like friends, which is why they trust him,” Jiang said. “Every day we see how he interacts with patients, and that teaches us a lot.”
Jiang pointed out that Kuo, though a world-renowned physician and professor, still rolls up his sleeves to examine patients’ wounds and drainage tubes when making rounds. He personally changes wound dressings for patients who are not recovering from surgery as well as he would like. And no matter how busy he is, he always does two daily rounds to monitor the efficacy of the medications that he has prescribed for his patients and to make any necessary adjustments.
Kuo stressed the importance of a mentor in cultivating a good physician, noting that everything that the mentor says or does absolutely exerts influence on the mentee-physician. He elaborated on this point with examples: “Suppose a professor always talks about how much money he has made from the stock market, or how much money he has pulled in from this or that type of surgery. Over time, his mentees invariably take on values such as those. Conversely, if a mentor always treats patients with their best interests at heart and empathizes with their pain, his students will most likely become loving physicians as well.”
An American physician, Dr. Edward Trudeau (1848-1915), said: “To cure sometimes, to relieve often, to comfort always.” This means that even though only a limited number of illnesses can be cured, physicians must do what they can to relieve their patients’ pain and always bring them comfort. Senior physicians often share this quote with young physicians. Dr. Jiang has discovered in Kuo the physician that Trudeau advocated, and he intends to follow in Kuo’s footsteps.
Refuse to say no
“The thing Dr. Kuo says most often to his patients is, ‘We’ll figure out a way for you.’” Jiang pointed out another characteristic of Kuo: He never easily says “no” to his patients. He believes that physicians should give them confidence and support, not discouragement and despair. A physician that says “no” and stops trying to help people who are already suffering and badly in need of support is like adding insult to injury. Although there are limits to what medicine can do, Kuo believes that it is the responsibility of a physician to try to break through, to not give up, and to not abandon people to face their difficulties alone.
Kuo attributes his tenacity and insistence to an encounter with a woman from Kaohsiung, the second largest city of Taiwan. She had been treated elsewhere for cervical cancer, which had impacted the nerves for bladder control and had left her unable to urinate. After many failed attempts to treat her condition, her doctor suggested she go to Kuo for treatment. Kuo was one of only a few doctors at the time who were willing to perform endoscopic bladder neck incisions on patients.
After the first operation, the patient was able to empty half of her bladder. However, the woman sought more improvement than that. Four more operations followed, which reduced her residual urine after voiding to within a hundred milliliters (3.4 fluid ounces). Still wanting more improvement—seeking zero residual—she asked Kuo for another surgery.
However, all those operations caused fistulas to emerge in her vagina and urethra, which in turn brought about hard-to-treat side effects. The patient returned to the hospital once every six months for her follow-up checkups, but she often left disappointed. Kuo himself had been very disappointed too. One day he said to her, “I’ve tried my best. Would you prefer to see another doctor?”
“How can you talk like that, doctor?” the patient shot back. She said that it had been a lot of work every time for her to travel all the way from her home in Kaohsiung to Hualien, but she had never thought of giving up. How then could Kuo give up? “Are you fit to be a professor?” she asked pointedly.
About eight resident physicians were standing right there around Kuo, catching every word the patient said. It was quite an embarrassing moment for the senior physician.
“She taught me a lesson,” Kuo recalled. “She helped me understand that I should be doctoring from the patient’s point of view.” He has as a result often shared with his students that it is inevitable that physicians encounter medical conditions that just seem impossible to treat. In those situations, it is normal to feel frustrated and be tempted to send the patient away. However, a physician should embrace a sense of mission. No matter how tired they are, they must keep trying to figure out a way to help their patients get relief. “You might be their last hope,” Kuo says.
Kuo says that occasions that cause frustration abound in urology. A case in point is the treatment of interstitial cystitis (IC), also called painful bladder syndrome. This is a condition that urologists the world over cannot seem to completely cure. It often causes recurring discomfort or pain in the bladder and the surrounding pelvic region. “Patients may feel a burning sensation, as if a piece of burning charcoal is stuck in their bladder,” Kuo explained.
Because IC patients manifest no outward signs of affliction, they are often thought of, wrongly, as just imagining their pains. Even physicians outside of urology may not fully appreciate their suffering.
Since the disease is hard to treat, many doctors refuse to care for IC patients. They simply refer them to other doctors. Eventually, almost all of these patients end up in Kuo’s clinic.
Kuo can no more promise them a cure than the other doctors can, but he says to them: “I’ll care for you the best I can. If I can’t cure your illness, I can at least help you learn how to live with it.”
Though fully aware that a cure is most probably elusive, IC patients, knowing that Kuo and his team understand their suffering, have gradually learned to live with their symptoms and to smile again.
“This is the best reward we physicians can hope for,” Kuo added.
Kuo believes that young physicians—standing on the shoulders of countless teachers—will surpass him in their ability to care for patients.
New tools, new expertise
On August 14, 2014, Hualien Tzu Chi Hospital started using the da Vinci robotic minimally invasive surgery system. Two dozen or so hospitals in Taiwan already had such a system at the time, but the one at Hualien Tzu Chi Hospital was the very first in eastern Taiwan.
Kuo was one of those who had pushed for the purchase of the system. He readily acknowledged that it would be a sure money loser because the small population in eastern Taiwan would leave the system under-utilized. He advocated the purchase in spite of this because, without it, the hospital would not be able to train its surgical residents in how to use this potent tool. The purchase was a good investment in education.
Kuo’s department got the honor of being the first to use the system. With the assistance of this precision robotic device, a team removed a man’s prostate. This patient had previously had a hernia repaired, which made the resection of the prostate much more complicated to perform. Without the stability and precision of the da Vinci equipment, it would have been all but impossible.
That inaugural surgery was a success. The man was able to thank the doctor with a sonorous voice just days after the operation.
In the two years since the da Vinci device was inaugurated at the hospital, its surgeons have used it on about 140 patients. Jiang was the surgeon for about a hundred of them. The urological team at the hospital have used the da Vinci system to excise tumors, reconstruct urethras, and treat difficulties in urination. They have been able to remove a prostate, located deep inside the pelvis, within two hours and without damaging nerves and sphincter muscles.
The team has achieved a respectable level of excellence. The da Vinci robotic surgery system has greatly improved the safety of laparoscopic procedures at Hualien Tzu Chi Hospital and extended the level of care that Kuo and his team can offer patients.
A physician uses the da Vinci robotic minimally invasive surgery system at Hualien Tzu Chi Hospital.
As Jiang builds up his clinical experience and expertise, he also continues to expand his research activities and publications—just as his mentor has amply done. Jiang pointed out that Kuo at times suggests potential research topics for his students to try. If he sees promising initial results, he provides more clinical cases for them to delve into.
Jiang recalled how his own first research paper had come about. When he was still a resident doctor, he performed an operation on a patient to treat urinary incontinence which involved placing a sling around his urethra. Kuo reviewed the ensuing ultrasound report and wrote “good position” regarding the placement of the sling. Jiang knew that textbooks at the time had not stipulated a standard location for such a sling. Curious, he asked his mentor how he had made the judgment about this sling placement.
Kuo admitted that he did not know for sure either—he just felt that it was the best place for the sling from the standpoint of structural mechanics. Since that was just a conjecture, he suggested that Jiang look into this topic further.
Jiang collected data on actual cases, compiled statistics, studied the literature, and spent two months writing a paper, which was subsequently published in an international medical journal. He even went to England to talk about his paper. This experience helped bolster his confidence and pique his interest in urological research.
Jiang said of Kuo, “He never pretends that he knows everything just because he’s a professor. He’s always humble in the face of the vast ocean of medical knowledge.” When students ask Kuo a question to which he does not know the answer, he does not get mad; instead he sees such questions as topics for further research to which he encourages his students to devote their energy.
Besides his care for typical urological patients, Kuo is also noted for his treatment of spinal injury patients with urological conditions. When he chaired the academic committee at the Taiwanese Continence Society, he held many seminars on the care of spinal injury patients to give young physicians a chance to understand and appreciate the difficulties these people face. He urged physicians to join him and do more for them.
Kuo has worked with spinal injury patients since 1989. As part of its third anniversary celebration, Hualien Tzu Chi Hospital held a free clinic for such patients. Hospital social worker Deng Shu-qing (鄧淑卿) invited Kuo to help out there. At the clinic, Chen Ing-ho (陳英和), then head of orthopedics at the hospital, cared for spinal injuries, while Kuo dealt with urination problems.
Kuo pointed out that urologists back then were rarely exposed to spinal injuries. What little knowledge they might have possessed about this kind of care most likely came not from clinical experience but from textbooks, which offered one-size-fits-all treatment protocols like, in Kuo’s words, “Open a hole in the abdomen [for the urine catheter] and ask the patient to return regularly to change the catheter.” With the help of the social service office at Hualien Tzu Chi Hospital, a group of spinal injury patients had set up the Spinal Cord Injured Patients Care Society. Kuo noticed that many core members of the society, despite being mobility-impaired themselves, were working hard to help others. They impressed him so much that he decided to pursue this field of medical care.
Kuo participated in free clinics for spinal injury patients every year after that and helped relieve their discomfort coming from such conditions as urinary tract infections, urine leaks, and renal edema. However, he also knew that there were many people whom the free clinics had not reached because their condition was too severe for them to make the trip to the clinics. Therefore, he decided to reach out to them.
The Spinal Cord Injured Patients Care Society provided Kuo with a list of people for him to visit. Carrying a briefcase containing a hand-held ultrasound machine, empty vials, and home care pamphlets, he traveled around Taiwan, visiting the patients in turn. At their homes, he checked their bladders and kidneys and collected their urine, which he took back to the hospital lab for analysis and record keeping. He examined more than 900 patients at their homes in 2003 and 2004.
“Many patients didn’t look good in the early days,” Kuo said. He cited the case of a Mr. Zhu, who had damaged nerves as a result of an automobile accident. After surgery and rehabilitation at a hospital, he was discharged and went home with a urinary catheter. He would press on his bladder to urinate, and he thought that was normal. But Kuo noticed that the man was pale, lacked any appetite, and was extremely fatigued. The doctor figured that something must have gone wrong.
Tests proved Kuo right: The man had renal edema. If he had remained untreated for just a bit longer, he would have had to begin dialysis. Kuo arranged to have him operated on right away. The patient returned to health, and now he has a steady job and a happy family.
During his home visits, Kuo checked on patients and taught them how to care for themselves. He remarked that many of the people that he had visited ended up going to the hospital to receive his treatment. Since both urologists and neurologists have become more involved with the care of spinal injury patients, such patients have better access to proper medical care. Kuo has been very happy to see this.
On weekends, he serves spinal injury patients in northern Taiwan, and he holds a regular clinic at Taipei Tzu Chi Hospital. The Spinal Cord Injured Patients Care Society has developed into the Spinal Cord Injured Patients Potential and Development Center in Taoyuan, northern Taiwan. Kuo and members of the Tzu Chi International Medical Association also go there to hold free clinics and pass on healthcare information when there are new members at this center.
Kuo is also active in the Spinal Cord Injured Patients Voiding Management Care Network. He recruits physicians throughout Taiwan to join the network, and so far about 20 doctors from 16 hospitals have joined. He sincerely hopes that the nearly 50,000 spinal injury patients in Taiwan can one day easily find local doctors who can care for their voiding needs.
Jiang Yuan-hong, one of Kuo’s students, tends to a surgical wound as he explains to a patient and her family how to apply artificial skin so that they can safely do it at home to lower the risk of infections.
Jiang was one of only three young urologists in Taiwan chosen for an inaugural exchange program between the European Association of Urology and the Taiwan Urological Association. This was the certificate awarded to Jiang after his participation in the program.
Now Kuo’s 30-year contract with the hospital is about to run out. When asked if he would renew it for another 30 years, he laughed and said that would be impossible. He added that it would be more important for him to instill in younger physicians the spirit of patient service and to transmit his experience to them so that the torch can be passed on. He wants to help make his students more effective than he has been.
He prays that all physicians in Taiwan, not just his own students, will cultivate a patient-centric mindset. Only then will medical care in Taiwan continue to improve and advance.