Demystifying Medicine One Month at a Time

Tag: China

Barefoot Doctors

DSC_4075The venerable New England Journal of Medicine published an opinion piece about why it’s important for us to learn about the history and current practices of health care in China.

Since the Communist Party declared victory in the Chinese civil war in 1949, health care in the People’s Republic has undergone rapid cyclical change, mirroring the various emphases the single-party government has proffered to its people — from collectivism to free market capitalism and then somewhat back again when >90% of Chinese were left uninsured — in what the authors of the piece describe as a movement to create professional norms for a medical profession that have not heretofore existed in China.

A good summary of the piece describing some of the implications can be found here. Other sources report that China is planning to double the number of primary care doctors in the country by the year 2020.

One concept worth learning about if you’ve never heard of it: “Barefoot Doctors.” Founding Premier Mao Zedong unleashed these “paramedical” folks into the countryside in the 1960s to offer help with prevention and primary care. One result: a stunning drop in infant mortality. The analogue in our own age is the concept of the community health worker, something that has garnered press and continues to be an alluring possible solution to our own problems of translating medical knowledge gains out into our communities.

Be Careful What You Wish For

Why our medical malpractice system is superior to not having one.

One of the topics I went to China to discuss was our medical school’s approach to teaching medical ethics.

At Wuhan University they have a first-year course, but I was told by both the school administrators and some of the students that the material is dry and not seen of immediate importance, so students often skip the class.

Here’s how it’s structured: 27 hours of straight lectures.

No case studies, no discussions, simply a professor of policy and administration who talks to them about morality, ethics, and offers only some specifics about clinical medical issues–like end of life or reproductive health.

Try not to be on the receiving end

The faculty deans at Wuhan have accepted the idea that to improve their course, they need to make it more case-based and interactive. To that end, the students want to hear from “real” doctors discussing cases that occur in their clinical practices.

I met several practicing doctors who are interested in helping improve the course. One of them is a cardiologist who became interested in medical ethics because of her own moral distress in dealing with angry families when a patient dies. She had spent two years in the US doing research, so had some frame of reference for how things are done here. “If something bad happens to the patient, the family can always sue. In China, it is not so.”

Instead, the family might openly grieve and become angry and aggressive. She reported that doctors have been attacked by angry family members, and in one instance she knew of, killed.

In her experience, even when a patient (and their family, as surrogate decision makers) had been duly informed about the risks and benefits of the proposed procedure (e.g. cardiac cath), and then consented to it, the family still became irate when the patient died–although this was not an unexpected outcome given the gravity of the clinical situation (an acute heart attack).

A member of one family kicked her, and demanded their money back. This doctor further told me that Chinese families typically demand a refund when a patient dies in a medical setting, and that it is often given as a matter of culture.

She estimated that this occurs about one or two times out of every one hundred patient deaths.

Thus, seeking more education about ethics (and implicitly the topic of patient-doctor-family communication) has become an imperative for her.

Makes you think.

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An additional note: In this superb NY Times article about the paucity of mental health care in China, the writer makes mention of hongbao, the Chinese custom for giving cash-stuffed envelopes to doctors in fields like surgery or cardiology. The article states that doctors can earn one-third of their income from hongbao.

Psychiatrists don’t get hongbao; this is only one of many reasons that Chinese medical students choose not to enter the field.

In America, we have a name for hongbao: it’s called concierge medicine.

It’s China(town), Jake

One of the more bizarre experiences I’ve had in medicine occurred on a recent trip to China.

Nicholson as Gittes: Best Movie Ever?

I’d been invited to meet with a doctor for a discussion and tour of Renmin (“People’s”) Hospital in Hubei Province. Before I went, she asked me to “give a talk.” Reasonably, she asked what  I was planning to speak on, though she indicated it would be good if I could talk about something in the category of “Functional GI Disturbances.”

Not being a subspecialist in that field (or any field, for that matter) I suggested that I’d be interested in learning about how hospitals in China are organized, or how health care is practiced, delivered, financed, and experienced. The kinds of things I think a lot about in these here United States.

We settled on “Clinical Ethics,” a topic that I could speak to, since I serve on GlassHospital’s ethics faculty and help in teaching the introductory course on medical ethics to first year students here.

I thought it would provide an interesting comparison of how health care is practiced in the two countries: would a “typical” American medical ethical dilemma translate into Chinese? What gives pause to doctors there and how do they work though clinically ambiguous situations?

I was a little nervous when the day came, never having rounded in a Chinese hospital before. I was also worried about getting lost in translation.

When I showed up, I was asked to “review the slides.” Always a good idea to mentally re-rehearse things.

I riffled though 74 slides. Not the ones I had sent. And wouldn’t you know? They were on GERD (gastroesophageal reflux disease) and NERD (yes, NERD!: non-erosive reflux disease).

The doctor who’d invited me was asking me to look over her slides, right? Maybe she wanted me to have a preview; maybe to make sure that things looked OK in English or in the medicalese.

I get it, I thought: reciprocal talks–first her on her topic, then me on mine.

“Looks great,” I told her. “Pretty detailed, in fact.”

“Excellent,” she smiled back. “Please proceed then.”

Huh?

You mean, you’re asking me to deliver a 74 slide lecture on a topic that I haven’t prepared in Chinese?

(OK, I was definitely not being asked to give it in Chinese.) But still.

I had been briefed in the pre-trip orientation about Chinese culture and the idea of avoiding shame and saving face.

And here I was, in front of 20-30 Chinese doctors and trainees, being asked to deliver clinical teaching rounds on a topic that I hadn’t prepared and in which I claim no expertise.

What would you do?

I felt the the heat on my cheeks, but to avoid causing offense, and perhaps because this was how things are done or at least interpreted, I jumped right in. I’m a bit of a ham, and I enjoy performing.

After all, the doctor who’d invited me had no doubt slogged away putting this beast of a talk together. And she’d done it for me! The least I could do was give her talk in clean, entertaining English. And let’s just say, at 74 slides, that there was a little redundancy built in.

Thank God it was on GERD, something I see every day as a practicing doctor, and not acoustic neuromas.

Oh, and NERD. I know a bit about that, too. Just never thought of it that way before.

By the way, later in the day I did get to give my talk on clinical ethics. It wasn’t nearly as fun as the one earlier in the day.

Diplomacy

I have a newfound respect for arms reduction experts, treaty negotiators, and diplomats of all portfolios.

Carter and Brezhnev back in the day

I’m honored to have been part of a recent delegation from GlassHospital U. to Wuhan University in Hubei Province, China.

The leadership of Wuhan’s medical school has embarked on an ambitious educational reform plan and has sought outside consultation to help with the effort.

Through past collaboration with a non-governmental organization in the combatting of AIDS in the province, relationships were built that led to a furthering of invitations and partnerships.

A flowering, if you will.

Such is the nature of diplomacy: Building carefully constructed relationships on top of one another in the furtherance of joint goals. It takes a lot of energy and hard work to pull it off. The unsung heroes of the effort are the interpreters, without whom the flower would quickly wilt.

The biggest diplomatic show of 'em all

We’re privileged with bilingual experts on both ends of the relationship. They not only make the agendas for our meetings take shape, they are with us most of the way, translating from one side to another and back again.

But it’s a lot more than words and phrases. It involves cultural understanding and hospitality; travel and accommodation arrangements. Food and entertainment. Logistics. And lots more food. In short, the whole kaboodle.

The dignitaries/delegates at these types of meetings that sign off on the joint memoranda of understanding (the “products”) get all the glory, but like many in the world who are under-recognized, it’s the interpreters that make it all possible.

My hat is way off to those whose facility with language helps us bridge our differences and make the world a more harmonious place, one small step at a time.

Ni hao from China

In our unremitting effort to make transparent all that is Medicine, GlassHospital has journeyed to China, home of the 2008 Summer Olympics.

The real reason we’re here is to facilitate dialogue and cultural exchange between two great medical schools, those being the one affiliated with GlassHospital and the one here at Wuhan University. Like many medical schools, Wuhan is looking to modernize its curriculum, emphasizing clinical reasoning and small group learning over the traditional large lecture format and rote memorization.

And, in an interesting twist, the central government has embarked on an ambitious health care reform agenda that among other goals seeks to produce more primary care doctors to serve the world’s largest population.

Hmmm, does this sound vaguely familiar? (Fodder for future posts?!?-ed.)

A couple of travel notes:

The GlassHospital family travelled to Beijing, China’s capital, on our way to Wuhan. There we saw incredible sites like the Olympic Park, Tiananmen Square and the Forbidden City.

At the Bird’s Nest stadium, famous architectural marvel and home to the track and field competition and opening ceremonies, we saw this interesting machine:

Health in a Box? (photo by SAH)

It wasn’t getting a lot of patronage, but still–we very much liked the idea of quitting smoking in a box.

Then, at the Beijing airport (a pretty fantastic architectural achievement in its own right), we were intrigued about the no smoking signs posted around. They had the usual circle-with-a-line-through-it around a cigarette, apparently sponsored by the “Beijing Patriotic Health Campaign Committee.”

That’s using civic pride to good public health effect.

A couple of other notes:

I’d heard about the internet filtering of sites like Facebook and Twitter. What I wasn’t prepared for was the blacklisting of many blogs that I regularly read. At first I thought that maybe folks like Dr. Grumpy had simply irritated the authorities with his clever and sometimes sophomoric humor. Then, when I also couldn’t find my favorite health policy blog, I thought they had my number. What had these medical bloggers done to be politically controversial?

Well, it turns out it’s a blanket proscription on all blogs Google; that is, if the blog is written on Google’s Blogger program, no dice being read in China. Apparently, it extends beyond Blogger blogs, too, but I’ll just leave it at that for now.


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