This is the essay I turned in to complete my China rotation. It's a little long, and wordy, but hey, that's me.
I really didn’t know what to expect of the Chinese medical system. Consciously, I didn’t think much about it; I was more concerned with what I needed to pack for a month overseas than what I would actually do when I got there. Subconsciously, however, I think I had more stereotyped ideas. China is a Communist country, and that brought up sensations of drab ugliness, poverty, dirtiness, and an inability to change. After all, I was raised during the Reagan era by Republican parents, and I think I internalized some of those expectations. I know I carried some of those stereotypes to China because I felt surprise when I entered the first few hospitals; even though I thought I hadn’t expected anything, they weren’t what I expected. During the month, we saw so many hospitals in so many specialties that I not only changed my expectations, but I can actually compare my experience in China with my American medical education and draw some conclusions.
The first hospital we visited, T, was known for neurosurgery. Our first morning at T we visited the operating rooms. I was surprised that the inside of the OR looked like any OR in the States. The CT and MRI films on the wall were high resolution; the anesthesia cart looked familiar, and the surgical equipment was advanced. In fact, the only shocking thing in the OR was the appearance of OR sandals (we were all given pairs ourselves), which seemed dangerous (OSHA would have thrown a fit).
In the afternoon, we visited the wards, where the difference was much more striking. Each room held eight to ten patients, plus several family members for each patient. There were no curtains or privacy walls, and the restrooms were down the hall for the use of the entire floor. They appeared to be less than sanitary. Each patient had a water jar or a baby bottle at the bedside; I assumed the baby bottles were for patients who were bedridden and couldn’t sit up. Each patient had a folder at the foot of their bed containing their films, which we could go pull out and examine at the bedside. Patient privacy laws must be less stringent than HIPAA, because we would discuss the case in the room in front of all the other patients and all the families.
The next day at T we visited the ICU. The ICU attending was very interested in American end-of-life ethics, and we talked for quite a while. We gathered that there are a limited number of ICU beds in a Chinese hospital, like ours, but they don’t seem to have LTACs or other places to send patients needing high-level care, so those patients simply remain in the ICU. Then, the family takes ultimate precedence over what happens with the patient. Thus, if a physician wants to transfer the patient out of the ICU (I assume because care is futile), the family may request that the patient stay. Every bed was full while we were there, and he seemed upset that families may request a patient to remain in the ICU even while other patients need that bed more. This is a situation that is at least similar to ones most of us have faced in the States, as there are never enough ICU beds for everyone who needs them (or so it seems). It did seem, from speaking to that attending, that few Chinese have any kind of DNR or Power of Attorney paperwork (or family discussion), which complicates the situation.
The most interesting difference is that they recognize brain death, but it is not a legal criteria of death. Therefore, if a patient is brain dead, they still have to convince the family to remove life support, whereas in the States (at least in those states that recognize brain death without qualifications) once those criteria have been met, that patient is legally deceased. Life support is withdrawn because the patient is not alive; it is a different situation for us than a patient in a vegetative state where life support is withdrawn from a patient who would continue living on it. I remember how much relief the brain death standard gave to the physicians when I was on neurology, because there were no tough decisions to make at that point; the patient was brain dead, therefore they were dead. It was much harder if the patient retained one brain stem reflex but otherwise had no cortical function, because then the family must make a terrible decision. All in all, the situations doctors face in ICUs regarding end-of-life are fairly similar in China and the United States.
At F Hospital two weeks later, another interesting situation arose. We were rounding on general surgery patients, and we met a patient who had arrived at the hospital with a small bowel obstruction. A CT of her abdomen showed a large sigmoid tumor which had caused her obstruction. As we took her history (translated through the resident), we asked if she knew her diagnosis (since we’d seen her case presentation before examining her). The resident explained that she had not been told, as most patients with cancer did not want to know. We were all shocked. Then who makes decisions? The resident replied that her family would be told of the diagnosis, and they would make decisions in her case. This was totally foreign to us, and several students were made very uncomfortable by this situation. Next, we examined two women with very large breast masses (in front of the other seven patients in their room), one of whom had large palpable nodes in the axilla. We asked the resident if these women knew their diagnoses. He replied yes, because it is “more obvious” when the problem is in the breast. All of us in that group have read the case in ethics where the family requests that the patient not be told her diagnosis, and the correct answer is of course to ask the patient how much they want to be told. When we asked the Chinese residents about this, they were puzzled; why would the patient want to know? I think they were easily as confused by our views as we were by theirs.
The biggest difference between our health care systems took the majority of the trip to elicit. We asked this question at every hospital, of every resident and attending, and received varying answers. Finally, at A Hospital at the end of our third week, a cardiology attending answered our question in a startingly truthful manner: what happens if the patient doesn’t have insurance and can’t pay? Answer: they don’t receive treatment. She was incredibly honest with us. She told us that even acute patients having a STEMI come to the emergency room and are required to pay for their stent before receiving it. If they do not, most hospitals can/will do nothing, so that patient simply does not receive treatment. If the patient has no means, the family will be pressed; this might work better in China than here because the family structure is very tight. As one might imagine, demanding cash up front delays the time before the patient goes to the cath lab, which had been confirmed in studies this attending had helped conduct. Now, in the States, money is a huge issue in our medical system, and I have watched many back-boarded, c-collared patients in the ER trying to sign insurance forms held above their heads while they lie flat on their backs. However, because of the EMTALA law, if a patient is in need of emergency care, they will receive it (at any hospital which receives Medicare funds). A truly private American hospital might refuse to stent an uninsured patient, or deliver their baby, but most hospitals are bound by EMTALA. China does not seem to have such a law. The hospitals we visited in China were all public hospitals (there are some private hospitals), and surely a public hospital should be required to treat the public (at least in my understanding of the word).
The Chinese system is much more capitalist than ours regarding payment for service. Much of the work American hospitals do is unpaid; in China, that hospital must receive a fee for their work. The fees charged are very low by American standards, because we tend to float the unpaid bills off those that are paid. So the price of a blood test is several hundred dollars, because the hospital will not be paid for everyone’s test. In China, the fee is lower, but everyone has paid for their test. In our system, we’re running into escalating costs because of the price of paying for the uninsured (among many other things); in theirs, their population just keeps growing. Rural areas are terribly underserved there (as in America, only worse), so there are always more patients who need the care than there are hospitals or doctors to care for them, but on a scale that most of us could not comprehend. After all, our system administers to 301 million people; theirs, 1.3 billion. Our system is overloaded; theirs must be bursting. Is it any wonder that we saw many paying Chinese patients receiving “extra” tests because those are cash tests? Of course, that kind of thing happens in the States, too, but we call it fraud. There, it was normal.
Overall, I learned many things about the Chinese health care system, and by contrast, many about our own. I saw the differences between Chinese and American medical education, and I am very glad I don’t have to learn medicine in Chinese (but Chinese doctors have to learn medicine in English). I learned a bit about Traditional Chinese Medicine, if only enough to know the terms to look up for patients in the future. I witnessed a living example of an ethical situation that had been only abstract until then. The Chinese system would be an excellent system to study here in America in the near future, when our health care system will be scrutinized and changed after the presidential election. Whoever is elected, I hope they can take some of these lessons to heart, because their system modeled interesting features of both capitalist and socialist health care systems, and in some cases, the worst features of both. Perhaps the most important thing I learned, though, was how similar our systems really are—far more alike than different. I’m much more conscious of my beliefs about the Chinese health care system now, and I’m no longer surprised by what I saw there.
Since I have nothing medical to blog about for the next three weeks, until they unleash me upon an unsuspecting neurology service, I'll blog about what I've been doing recently, and that is reading.
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