Medicine in China and the U.S.: Observations from an American Medical Student – Review Version

Inspired by a post from Stephen Eigles, Medicine in China and the U.S.: Observations from an American Medical Student, I come to this post about Chinese medical system.

The post was written in 1998, Spring, 2 decades ago. However, the insights in this post are still pretty relevant to this day.

Some, mispractices, have been eradicated from China for quite some time now, but the rather baffling and ominous wrongdoings are still very persistent to this day.

I went into hospital just 3 months ago. Contracting a strange disease, I couldn’t walk on my feet at the hardest time. The journey of fixing myself was, pretty excruciating. It came from point A to point Z, and still little to zero clues were proved to be useful. Doctors pushed me around for not consulting the right department, and I was desperate for a cure.

After I came out of hospital, my conditions were less severe, however the symptoms never really went away either. They just impact less severely on me now. I can still feel pain and strange symptoms from time to time in my body, what a painful experience……

My notes on this post are labeled with yellow color.

 

Last summer Stephen Eigles, a 4th year medical student at Georgetown University, spent a month studying infectious disease in a teaching hospital in the remote city of Jiamusi, Heilongjiang Province, China. He shares his experiences and views on the similarities and differences in current Eastern and Western medical practices.

During my four-week rotation at the Department of Infectious Disease in Jiamusi, I was involved in every aspect of infectious disease protocol, including emergency room admissions and working with the 12 departmental doctors, five nurses, and 20 to 30 patients whose family members usually cared for them on the ward. As most hospital patients stay from two weeks to a month, we all had ample opportunity to become acquainted.

Although I spoke Chinese fluently, the doctor assigned as my mentor spoke English, had a master’s degree, and was one of the most knowledgeable on the ward (only one other doctor in the department had graduate training). Working together, we learned much about each other’s medical systems, and about our own as well.

Ninety percent of Chinese physicians have no degree beyond a bachelor’s, and yet enjoy the same responsibility as their colleagues who hold master’s degrees and doctorates. While hospitals value advanced training, a tremendous brain-drain draws talent away to more economically developed coastal cities and abroad. Shortly after I left China, my mentor accepted an offer from a hospital in Guangzhou, thousands of miles to the South.

The resources are still unevenly distributed based on how well developed a city is, and how free it is (beneficial policies for local economy and public services). Resources are also concentrated in the few costal and geopolitical-supervised cities, namely, Beijing, Shanghai, Guangzhou and Shenzhen. Cities other than the major four ones are neglected in many ways. And hospitals based in each of these cities have a tremendous difference on medical equipments and quality of staff, based on different geographical regions. The central economy zone in a city has the best hospitals and best staff possible, whereas hospitals in urban areas are cut down a significant level.

China has no primary care doctors; all doctors and clinics are hospital-based. When patients arrive, a reception-desk nurse decides which department they will be admitted to, based on the symptoms they volunteer. Each department has its own ward, and manages its patients with almost no interdepartmental consulting or transfers. The Chinese medical system emphasizes empirical rather than book learning, and all doctors are specialists, so their diagnoses and treatments tend to be selected from a very narrow repertoire. This system generally works well for common problems, but if the admitting nurse misdirects a patient who requires multiple-specialty expertise, or who has a rare condition, the patient tends to have a poor outcome.

No communication still happens today, the patient that is supervised by the very department has no outer sources, unless the patient specifically requests, to help diagnose or prescribe medicine. As a person lying on his sickbed, there is no way he is going to know his problem is multi-divisional, let alone requests. Patients come to hospitals for knowledge specialty. The department hosts meetings routinely, however normally not involved with other departments. I remember when I walked by that meeting room in my way to dining hall, it was filled with nurses and doctors for specific cases. But that was completely one department’s internal meeting. 

A good doctor is valued by what? His experience? Or his knowledge? I won’t know, I don’t work in the healthcare. However, I don’t think the extremes of both sides would give any good result. But I can testify that Chinese doctors do prefer empirical knowledge over theoretical knowledge. Step aside from this debate, what blinds the doctors here is specialization. Much as what Eigles wrote in this post, specialization makes them unable to diagnose or prescribe any medicine for rare diseases. Every doctors is specialized in one way or another, and the specialization is focused solely on one or two rather common diseases. From this time of pursuing right doctors for my rare disease, I have this profound discovery of the system that it is unimaginably unfriendly towards rare conditions. 

If problems are typical, and obvious, doctors usually can diagnose and prescribe effective medicine very quickly, based on their long term experience combating the same type of disease. When problems are atypical, doctors have a hard time to tell what the problems are and where the cause is, whilst relying heavily on their experiences rather than notes taken from researches and books. 

Are experiences bad? Certainly not. I do believe a surgeon heavily trained by his empirical practices definitely performs better than a notebook surgeon in field. However, it is necessary to acknowledge the knowledge from the past, most of the time experiences are just repetitive evidence to prove a point tested from the past correct.

This incompetence towards rare conditions is something I think the Chinese medical system needs to improve. 

Economics plays an increasingly central role in American health care, but in China it is frequently the overriding factor. Chinese hospitals cannot operate “in the red,” so when a hospital’s cash flow deteriorates, salaries in the money-losing departments stop immediately, whereas in the U.S. the administration usually manages to arrange for continued operation. Chinese patients must pay a deposit of over half their anticipated expenses before they enter the hospital, and services halt the moment their account runs dry (each patient’s balance is posted on the ward daily). Doctors carefully analyze and explain every expenditure to their patients in advance, but patients frequently still become heavily indebted to family and friends, and risk medical abandonment if they cannot raise cash quickly enough. While such practices now sound abhorrent, they used to be common in the U.S.

I experienced paying money upfront, even though my expenses were mostly covered by state healthcare insurance. What “mostly” means, it was actually just half of my expenses. I was told the expenses could be reduced to 20%, but that was completely not the case in reality. There were many other expenses not covered by the state insurance, and these expenses had to be paid by the patient upfront. What the state insurance covers are rather common and basic tests and drugs, if conditions are not common, you are screwed.

The bills. They came into my ward every day. The bills were merely medical expenses you have incurred, however, you don’t feel good to see them piling up each day. 

I did not know this practice was so “conventional” that it was like this 20 years ago as well.

What boggles me here is the time. If the U.S. once experienced such horrible monetary conditions back then, that means it is a process. However 20 years have passed, although the situations are definitely loosened, the same practice still exists and it does not seem like I was going to be magically saved by anyone if I did not pay the daily upkeep. In the short stay of about a week and a half in the best hospital in my city, I was warned at least 2 or 3 times to pay up the bills. 

So apparently this operation rotating around money thing still persists. 

 

“Danger” is a relative concept.

In the U.S., avoidable risks are unacceptable, while in China, many doctors are more cavalier, relying on the empirical risks observed in personal experience, rather than the theoretical risks learned through re-search. The Chinese legal system hasn’t yet developed sufficiently so that Chinese doctors risk malpractice suits.

20 years have made some improvements of the legal system, however, the relationship of doctors and patients can turn out to be very ugly in direct contact. People generally don’t seek legal assistance first in their pursuit of compensation from malpractices. Usually they just go on and beat either the doctor or the nurse, it gets physical every time. And this problem has become increasingly prominent in the past decade. 

One night when I was in the emergency room, the police carried in two comatose men wrapped in bed sheets, victims of tranquilizer poisoning — and who had been robbed in their hotel room. The pair hovered between life and death for a full hour until the hotel owner arrived to pay for the antidote to be administered. After the men had walked out of the emergency room with instructions not to be alone for a while, I found that nobody on staff knew whether the effect of the antidote would outlast the poison in their systems.

I think this problem has been solved with 2 decades as doctors now generally understand the side effects from drugs. 

Although China is less economically developed than most Western countries, Chinese hospitals can deliver highly technical care. This remote teaching hospital in China has a major investment in modern medical equipment, including a CT scanner, an MRI, and dialysis machines. Unfortunately, few patients can afford to use this equipment, although modern medicines and vaccines are available in China at five to ten percent of U.S. prices, and domestically-produced generic brands cost only pennies. The hospital library, impressive with over a thousand Chinese and foreign journals, had many inexpensive, illegally mimeographed editions. The li-brary’s catalogue is not computerized, but in the past year the Internet has reached most cities, including Jiamusi, and institutions are now being wired. It was apparent to me that doctors are discouraged from using the library during working hours, the only time it is open.

Three things here. First, the medical equipments. Top hospitals are all equipped with state-of-the-art medical devices. All the hospitals I visited 3 months ago were equipped with an MRI, sometimes even double, CT scanners, Ultrasonic Detectors, and apparently other advanced equipments. Second, the state healthcare insurance definitely covers the expenses of these machines, and they are reduced up to 80% if you are a local resident with local state healthcare plan. What I figure is that workers without local ID, people come from other cities and outer provinces, can have like around a half for the reduction. I guess that’s also good. But it only happens if you get into a ward, otherwise you need to pay pretty much everything if you are just consulting and asking prescriptions. Third, what I found amusing was the time when my diagnosing doctor was actually searching on Internet for my symptoms. I guess since information is so open today, doctors have freedom to access knowledge everywhere. It is not the case anymore, although I do find searching on Internet for patient’s symptoms not quite professional 😆

This policy may be a reason why certain medical knowledge in this remote hospital appears to lag as much as 10 years behind the West. And yet, relative to basic public health and medical practices, Western advances in high-tech research and treatment have not significantly advanced either quality of life or longevity in many areas. Some medical practices I observed in China quixotically appeared to be more scientific than those in the U.S.

For example, American phlebotomists routinely take a separate, full 5-cc tube for each group of blood tests, and, if drawing through a central venous line, will draw off and discard the first 5 cc. Hearing of this practice left my Chinese colleagues’ mouths agape. Many Chinese patients believe blood does not quickly regenerate and are loathe to give it, so doctors are trained to scrupulously take only what they need — generally just a few drops — as state-side doctors do with infants.

To be frank this still persists today, if one does not need to do blood test, he doesn’t need to. Doctors tend to use the least physically painful method to diagnose a patient. But when some tests are necessary for diagnosing specific diseases, a patient needs to do what the doctor asks. 

A certain degree of mysticism continues to pervade Chinese medical science. Traditionally, Chinese have believed that the manipulation of “Qi”, or life-force, is a key part of treatment, but now new pseudo-sciences have emerged, such as a belief in the curative power of magnetism and far-infrared waves. Chinese are not alone in looking for miracle cures in alternative medicine or religion, but belief in pseudo-science has overwhelmed the scientific training of some Chinese doctors. At the invitation of a colleague, I attended an off-campus lecture on the healing powers of far-infrared waves and magnetism, delivered by a doctor from the highly-respected Tianjin Medical College. The audience heard a story about the first astronauts in space who suffered space-sickness because they left the Earth’s magnetic field, and were told that all spacecraft are therefore now lined with magnets. The story was a sales pitch for very expensive bed mattresses that could provide these forces, and cure or prevent infection, cancer, atherosclerosis, pain, and many other problems. The lecturer described how far infrared waves could provide the body with extra energy, and how magnetism kills bacteria and viruses. These no-energy-source-needed infrared-magnetic mattresses sell for 4,500 RMB — more than one year’s salary for most Chinese. (Several of the more educated doctors in the department refuse to endorse this quackery, but at least two on our staff were selling units to their patients.)

This certainly does not exist anymore. 2 decades are enough of cleansing weird and superstitious beliefs out of public’s minds. However, this doesn’t necessarily prove that superstition is completely eradicated. The pervasive public practice may have stopped already, you won’t find strange people selling strange drugs to you, snake-oil like weird drugs. But I can find the charm of pursuing miracle cures. When you are desperate, everything seems to make sense, no matter how detrimental and harmful it may be. You will try literally everything to rid the disease out of your body. I remember reading some strange and superstitious ads on Internet about how to rid “spirits” of your body that are causing all the problems. 

The practice of selling hope. Whilst every hospital and doctor are selling hope in one way or another, it doesn’t prevent other unqualified personnel to sell hope as well. The country though has struck down several deceptive and superstitious practices in general, they continue to survive in a fashion of changing masks. Since Chinese the language and culture are so complicated, it is rather obvious and simple for these mispractices to seek existence by rephrasing and redecorating themselves. 

For many Chinese, hospital admittance is a last resort. Most patients at this hospital are poor peasants, and for many common diseases, such as hepatitis B and liver cancer, the hospital charges fees well beyond their means while offering little hope of a cure. One can understand the allure of traditional Chinese medicine that sells hope at a reasonable price and can be taken in the comfort and safety of one’s own home.

Generally, if you are rich, you will have much less problems dealing with diseases. Disease, is a privilege for the poor.

Traditional medicine has a legitimate place in China, regardless of its medicinal value. But it has an unfortunate impact on the practice of scientific medicine, because some doctors have trouble separating the two. Without any formal training, a few doctors in the department do prescribe herbal medicine, against the chief’s wishes. In one case, a poor 45-year-old man with ascites spent all day waiting by the main entrance of the hospital, hoping to see a certain doctor in our department who had prescribed traditional Chinese medicine that helped a neighbor in his village, five hours away. The doctor accidentally ran into the patient late in the afternoon. The man obviously could not afford the expensive Western tests and treatments warranted by his condition, so the doctor simply prescribed the same inexpensive medicine that had worked so well for the neighbor, and the patient left. Prescriptions for traditional Chinese medicine do come from textbooks, but the formulas differ in every text, and are supported only by a few patient histories of miraculous cures. There are no references or studies available because there is no funding to test non-patentable herbal products — a problem the U.S. also faces. To circumvent this problem, some Chinese companies are now selling “patent medicines” they claim to have tested. Unfortunately the studies and ingredients are secret.

What is strange in the modern Chinese medical field is this distrust towards traditional Chinese medicine. I remember when my supervising doctor expressed his opinion on traditional Chinese medicine, it was rather a contempt. However, I have much more faith in traditional Chinese/herbal medicine than western/scientific medicine. He believed as long as the medicine can cure you, it was ok to take them. 

Usually side effects from western medicine are huge, at least here in China, there really aren’t any western medicine I’ve taken that have zero side effect. All of them have side effects in one way or another. However, herbal, or traditional Chinese medicine do prove to be much side-effects-less. And they prove to be very effective towards internal diseases, self-inflicted ones. But I never really want to cure myself for a flu or a fever by drinking solutions of traditional Chinese medicine. Because that takes too much time, western medicine are fast and effective, however it comes with a price. 

I think, it is necessary for traditional Chinese medicine to get a legitimate place in medical field. They have been practiced for thousands of years and prove to be useful before western medical knowledge came to China. They only need more exposure and research, studies and more textbooks to back them up, in order to achieve academic legitimacy. 

And to be frank, traditional Chinese medicine and western medicine are completely two different branches. Traditional Chinese medicine don’t work the scientific terms western medicine use, it is all about “Chi”, life energy, vigor, and how you treat your own body. Since they are two completely different subjects, I believe it requires some translation in order to achieve understandings of both sides. And for the prosperity of traditional Chinese medicine, people can’t see it as more of a superstitious act of treating diseases. It is definitely not superstitious, and it is useful and proven by thousands years of cured cases. Science in the west is still developing, and it is pretty obvious that today, science is still rather rudimentary in terms of understanding our universe. There are substances not discovered, let alone classified. So I believe we need a very mature and data-backed system for traditional Chinese medicine in order to make its place and save more people. 

I left China with the feeling that I had traveled back in time to the state of medical deregulation the U.S. evolved from not so long ago. While China does not have cocaine in its soft drinks, no one knows what is in them. The evolution of the medical system in China is fascinating. Sooner or later, it will give up snake-oil patent medicines in favor of accurate labeling, and untested herbs for scientific rigor. The government will one day begin enforcing the regulations already in place; the public will demand it and will hold their medico-legal system accountable.

By investigating China, I learned more about The U.S. One of the biggest problems in the present training of doctors in China is the paucity of physicians with advanced degrees. Although graduate-level physicians and those who hold a bachelor’s degree differ by only one or two years of additional classwork and research, bachelor physicians have a very different mentality from their graduate colleagues. Less educated doctors prefer empirical symptomatic treatment (i.e., a Western/traditional medicine mix), while diagnostic disease-based therapy (i.e., Western science-based medicine) is prevalent with graduate-school physicians. The bachelor-degreed physicians may lack an understanding of the scientific method and its importance to the practice of medicine.

I see in the Chinese situation an ominous lesson for the U.S. regarding the way we are currently downgrading of our standards for primary care. While General Practice has strengthened itself by evolving into Family Practice, we have handed off more responsibilities to nurse practitioners who are less well-trained than most doctors. Certainly, nurses can handle many routine complaints most of the time, just as can bachelor doctors. But we must ask ourselves if we are willing to settle for a less skilled, less scientifically rigorous approach to medicine that handles cases appropriately most of the time? We have yet to answer the questions: how much risk are we taking, how much are we willing to take, and how much are we saving by transferring so much primary care from MDs to nurses.

We have yet to even seriously ask these questions.

 

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