Culture Sample: what Americans might learn from Chinese health care.

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.

[Updated: My friend Jen Ambrose points me to a study (in pdf form) that concludes, among other items, family involvement in an American hospital improves outcomes and lowers costs. ]


  1. ironic that so many of the Chinese doctors I know are embarassed to show foreign doctors the wards crowded with family members.

  2. An interesting post, and an interesting reflection. At what point do we reach when, without noticing it, things China become accepted as common practice and things native become foreign?

    I do not know, but would be interested in the breakdown in behaviour in Taiwan and HK, both systems different from mainland China’s, as a way to judge how much is cultural and how much is a response to perceived fear of healthcare practioners’ negligence/malpractice.

  3. Nice analysis, describes precisely the atmosphere in the Chinese hospitals compared to Western. However, having discussed this before with doctors in my own family, I think the disadvantages of the Chinese style hopsital are a bit under-reported.

    In particular: 1- Excited family members disrupt work of the medical staff, 2- it is impossible to obtain the silence and calm that patients require, 3- hospitals are great places to catch infections for the whole family, and 4- it is much more difficult to maintain the required higyene standards when 100s of people wandering around in the building.

    In spite of all this, I have to admit that as a patient, I would prefer to be given the chinese treatment. It is more humane, and I’m sure psicologically it has beneficial effects on the patient (which can make him recover faster)

  4. So you notice how a few knobs on a machine work and you know what is going on with the patient better than the dr. and nurses? Such a journalist…

    As you mention the cultures are different because people don’t trust Chinese doctors nor is there much chance of recourse. It’s more out of necessity rather than wanting to be there in China.

    Having spent quite a lot of time in hospital myself and visiting others I have to say that I prefer being left alone much of the time to rest. Visitors are great but when you’re in a state of sickness it can be draining to put on a brave face.

    I’d argue a system where family members visited wards more often would actually cause more hysteria and prevent professionals from prioritising their work. Emotional relatives competing for attention to make sure their patient is being looked after?


  5. I’d have to agree with you “Doc”. My wife’s recent visit to the Hospital, included twice-a-day visits by me, examining and challenging every procedure by staff.

  6. You know how Chinese and American hospitals are different? Ever notice how, when you’re in a Chinese hospital, you never notice “that hospital smell”? It doesn’t exist, but it’s all you smell in an American hospital. “That smell” is disinfectant.

  7. Thank you for the thoughtful post Adam.

    I too have had a lot of experience with Chinese hospitals in Beijing both with myself as a patient in shared rooms, and with my wife being hospitalized for 2 weeks in a cubicle ward after a stroke. I am not sure about the trust factor. There are actually wai di ren illegally available for hire at hospitals to be “bao mu’s/caregivers/bed pan removers” for patients that are out of the “official” bao mu for hire orbit (we got stuck in the middle of a bureaucratic power wrangle on that one), so not every one at every minute is a relative.

    The overall care was excellent though once you got a bed in ward(my wife had to spend one night in a big room with about a hundred patients and families etc. on wheel away beds). The cost is very attractive for sure. Vern is only partially correct about that disinfectant smell. I actually smelled that chinese medicinal herb smell that one gets in a medicine shop and it was most strong outside the laundry that I passed every day.

  8. Is there any special reason that you didn’t mention the practice of giving red envelopes to doctors to encourage better medical care? It goes right along with the lack of trust theme you’ve picked up on. I got the impression that bribing doctors was still pretty common, despite the laws against it. My boss in Taipei did it when his father was in for serious treatment, as did my Chinese teacher’s family (in Tianjin) when he was in for eye surgery. They said without the bribes they fear the doctor won’t give good care. At the time I was amazed at how little they trusted their doctors.

    Interesting post; i’m linking to it.

  9. The lack of privacy was a difference that really stood out to us when we went to the regular hospital in Tianjin for my wife’s first pregnancy ultrasound. It was a little bit like a train ticket booth; people were shoving their paperwork at the doctor before he’d even finished with the current patient, never mind that she’s partially exposed. People didn’t seem to want privacy in that particular situation, either — a woman right in front of us all said “I want an abortion.”

    Just our impressions from one visit, but still, it made an impression!

  10. The US and Chinese health systems are similar in that they are biased against the poor. If you have money, you get better treatment. In the US you need to have health insurance. In China you need to have cash to pay the doctors and the hospital. Does having Chinese-style ‘family support’ really make a difference to your outcome in hospital? I’d rather be in an ‘impersonal’ hospital that provides care which is evidence-based and in line with best practice guidelines, I think. I’d rather be in a hospital where I can be confident that the drugs are genuine and where the hospital is not getting kickbacks from suppliers for favouring one particular treatment. I’d like to be in a hospital where the doctors are free to offer conservative options (ie no treatment) rather than one where they have a financial incentive to offer expensive tests and treatments.
    Yes, cultures are different, but that’s no excuse for failing to offer patient care that meets basic standards.

  11. Some good comments. One general clarification: my point in this post was more general than specific. That is, family involvement in hospital stays, in my recent experience, is helpful. That seems to be understood better in China than the US.

    Some specific responses –

    Comment #3 by Uln – The four problems you list are a good counter-point to my thoughts. I agree with all of them – especially those related to hygiene and infection. There needs to be some balance, obviously.

    Comment #7 by Jen – Thank you, as always, Jen. That study is helpful, and I’ve appended it to the end of the post.

    Comment #10 by Joel – I thought about mentioning red envelopes/bribes, but decided aginst it for space considerations more than anything. But yes, it gets to the trust issue, as well, and is a very, very serious problem in its own right. A few years ago I was invited to join an elaborate banquet put on the for the surgical team that was to operate on a friend’s mother.

  12. Three more barriers to family vigils in US hospitals:

    1. IF you’re lucky enough to have insurance, and especially if you’re not, you’re going to get the closest thing to drive-through treatment as possible to avoid malpractice.

    2. Even with FMLA, it’s difficult to get time off work to spend 24/7 at a relative’s bedside. Maybe a spouse, certainly a child, but your mother or MIL? Good luck with that. Most people can’t afford the unpaid time off.

    3. Having access to the treatment regimen? What’s Mandarin for HIPPA?

    You’re absolutely right, it’s more about cultures than systems.

  13. Interesting observations; I’ve been thinking about this ever since that Atlantic article suggesting that patients pay out-of-pocket for routine medical care (keeping insurance for catastrophic and chronic conditions) as it resembles somewhat the situation in China.

    The advantage of patients paying for routine care is that it makes care more competitive – thus reducing waste and improving service – and makes consumers more aware. While doctor corruption is a big problem here, the lack of the blind trust you see in the US is probably a good thing.

    I definitely appreciate the affordability of decent (if unfrilly) medical care available in China, while recognizing that it means I have to be buyer-beware and do my research. I have often had doctors here proscribe superfluous treatment that, if insurance was paying, I would have taken; but since I was paying, and since I’d researched, I challenged them and they admitted it was unnecessary.

    I think there’s a lot more to be explored in the goods and bads of the Chinese system, as compared to US etc systems. I’ve come away thinking that the US health insurance industry is a corrupt corporate racket, a giant economy-devouring ponzi scheme; and am glad I’m not beholden to it despite the problems in the Chinese system.

  14. Apart from the emotional attachment of family members, I think the main dilemma in China is the available number of caring nurses and services with the large quantity of patients in one single hospital. I remember people were still struggling for getting a bed in the hospital when I was young. Of course, pricing is also a problem to the family to afford.

    Well, things also heads for different direction now. I have seen luxurious hospitals with perfect care for those who are wealthy enough or lack of caring relatives around. But the for mass, the vigil thing would still last for quite a while…

  15. I was doing a study recently that dropped the interesting statistic that Hangzhou has 3.9 doctors per 1,000 people, compared with 1.5 or 1.6 in Hong Kong and Singapore. Statistics may not be comparable I know, but I wonder how this impacts on the quality of care…
    My own experience with Chinese hospital care is pretty minimal, but the one time I did go the crowds were certainly the thing that I noticed most. Also the patients wandering down the street outside in their pyjamas, which is not something I’d seen in the west before!

  16. Thank you for this, it added to my understanding of the situation. I wonder if “visiting hours” ever prevent people from sticking around in US hospitals? Even in China, I’m sure there are times hospital staff prefer visitors to go home.

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