Roughly half-way down the list of things that expats in china are most often asked by folks back home is some variation of “what’s the health care system like?” I’ve visited enough Chinese hospitals and clinics to provide the answer that everyone kind of expects (“cheap” [for an expat], chaotic, highly efficient, not to ‘western’ standards) but I’ve never really been able to put my finger on what – precisely – it is that makes Chinese hospitals such culturally foreign experiences for expats (two of my favorite China bloggers might have had more success, here and here). And, conversely, what makes American hospitals so foreign to Chinese.
Part of the problem, I think, is that I’ve always thought about this in terms of health care systems. But what I’ve realized over the last few weeks (due to events I’ll describe) I really should have been thinking about health care cultures.
Let me explain.
Back in January, a very dear friend was admitted to one of Shanghai’s very best hospitals for several weeks of intensive treatment. Then, as now, I was no stranger to Chinese hospitals. Regardless of the type of hospital or clinic, and its location, my foreign eyes usually pick up on the crowds, first. And not just the fact that there are lots of people around, but that there are lots of people – relatives and friends of patients, to be specific – spending their days and nights living in the hallways, the rooms, and even renting empty beds. Most patients have resident support staffs made up of their closest relatives and friend.
So it was with my friend at the Shanghai hospital. In advance of her admission, her friends commiserated, and arranged a several week, full-time vigil beside her bed. Duties included: supplementing hospital meals, fetching nurses, conversation, errands and – most important – watching her condition during the twenty three hours and fifty-five minutes per day that weren’t attended by a doctor.
As anyone who has spent any time on a Chinese surgical ward knows, this is commonplace. It’s one of the reasons Chinese hospitals are so crowded – day and night – and it’s also one of the reasons that friends, family, and noisy neighbors typically know more about, say, the guy in the bed next to theirs than the world-renowned expert who might be treating him.
Why do Chinese people do this? To be sure, Chinese families are tight units – especially in times of crisis. But there are other factors in play, too. For example, right or wrong, there’s a widespread belief in China that the medical system is rife with fraud – fraud committed against patients. This belief, combined with limited to no legal remedies for patients who are victims of medical malpractice, encourages a mistrustful patient culture – and lots of people in the surgical ward watching every last move of the doctors. On a related note, China’s limp medical insurance system all but guarantees that hospital stays are paid for out-of-pocket, and – as a result – people paying cash for care take a keener interest in value than somebody whose insurance pays for most of a hospital visit (the need to save for catastrophic medical care, rather than frugality, is the real reason that the rural Chinese savings rate is so high). Finally, nursing care is an “upcharge” at many Chinese hospitals, and so many if not most families of modest means, paying out of pocket, will elect to take care of the bedpans (proverbial and real) on their own.
Cut forward nine months, to the last several weeks, and the quiet hospital room where I spent days beside the bed of a relative. From the first afternoon, I was struck by just how quiet the rooms and hallways were; mostly, they were occupied by nurses, orderlies, and doctors (in that order). Visitors, when they appeared, were rare, quiet, and quick. The patients across the hall were as sick – if not more so – than my relative, but they were alone for all but a handful of hours during the week I spent there (not to make myself sound heroic: my presence was a function of who was sick, and the nature of the schedule that my job allows me; I’d make a poor saint).
Doctors visited twice per day, usually, for no more than ten minutes at a time; nurses visited more often, and seemed to know more about what was going on. And then there was me: I was there all of the time, I quick learned to read the various monitors, and search for the visible manifestation of certain conditions. In time, I knew more about what was going on than the doctors and nurses. Finally, after several days, it occurred to me that – had I not been there to observe and report – the medical staff wouldn’t have had nearly as much information available to make educated guesses on how to treat the difficult condition in question. Likewise, I couldn’t help but notice that – due to my presence – they spent more time with my relative, than with the patients who were left alone. More important, they avoided prescribing drugs that almost certainly would have been ordered had I not been there to observe certain things. I’m no genius; no, I just happened to be there.
So. On the second to last afternoon, the primary physician treating my relative said to me: “It’s so much easier to do our jobs if we have families engaged and here. We can make better decisions.”
I don’t think most Americans would be surprised to hear this. But I do think, in general, most Chinese would be shocked that a doctor would feel compelled to say this. Of course a family is going to be engaged in health care decisions (for some of the reasons that I listed above) – even if that means spending a week in the hospital, sleeping by a bedside and changing-out bedpans.
Why do so many Americans leave their relatives unattended in hospitals? American families tend to be geographically fragmented (I’ll leave other sorts of fragmentation to others), making such vigils difficult. Also, I tend to think that Americans trust their doctors much more than Chinese trust theirs and – critically – they have easy legal recourse if they’re disappointed in health care outcomes. Quite simply, a certain level of trust is built into the system. Whether that trust in the system (and its technology, including pharmaceuticals) actually results in better care is another matter altogether.
And this gets at what I meant when I referred to a health care culture as opposed to a health care system. In reflecting upon my visits to Chinese hospitals and clinics, I’ve begun to realize that the rarest of sights in Chinese medical facilities is a single person unaccompanied by family or friends (those single people are invariably white foreigners). This isn’t a phenomenon just restricted to the wards. Generally, medical care in China is a family affair – for better or worse (the worse part being the circus atmosphere that sometimes pervades Chinese hospitals). That’s just not the case in the US.
Does it make a difference? I’d love to read a study that looks into whether or not family/friend engagement with health care decisions reduces medical errors (and I’m grateful that I won’t have to figure out how to design and fund said study). I’d bet in the affirmative that it does. In the meantime, I’d love to see a public service campaign encouraging Americans to go to the doctor together – if they have to go at all.