By Stephen Eigles '90
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 assign-ed as my mentor spoke English, had a master's de-gree, 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.
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. 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.
"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.
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.
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.
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 signifcantly ad-vanced 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.
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.)
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.
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.
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.
Isee 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 respon-sibility 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.