Having been working for more than ten years in the Department of Obstetrics and Gynecology in Peking Union Medical College Hospital (PUMCH), I have gotten accustomed to the busy clinical work, been used to the crowded clinic: isn’t this medical work? In 2012, I visited the Cleveland Clinic in the United States. I was astonished to see that the Cleveland Clinic was like a hotel! The health care gap between China and the US is the most treasure thing I’ve learnt during the year I stayed in the US besides medical professionals: there are still too much to learn from American medical service.
It’s truly enjoyable for American patients visit clinic. They may fully communicate with the friendly and skilled experts.
The root of the gap
Does it have anything to do with the population? Not exactly. Data from the World Bank in 2010 showed that there were 1.5 practicing doctors among every 1,000 Chinese, and this number was 2.4 among 1,000 Americans. The difference between both countries is not big, which is of course small as well in the gynecologists and obstetricians. There are 1.3 billion people in China. Statistics from Chinese Medical Association of Obstetrics and Gynecology in 2008 showed that there were 190,000 gynecologists in China, that is to say, every 6,842 people share one gynecologist. This proportion is equivalent to that of the United States: 42,000 registered gynecologists out of more than 200 million people in 2009, every 6,742 people have one gynecologist. So population is not the key factor.
Quality of the doctors’ service
In China, the regional difference is evident. In developed urban area, patients may visit well-known experts, but still, there are 2A hospitals with less advanced equipments than 3A hospitals. How about hospitals in counties? Medical resources are much poorer.
However, this regional difference does not exist in America. Doctors all over the country are almost on the same level. What impresses me most is that once I visited Liu CY, former chairman of the American Association of Gynecologic Laparoscopists (AAGL). Instead of staying in a big 3A hospital, he runs a gynecological clinic with his students. The clinic was in a rented building at the roadside in Chattanooga, a small town in Tennessee. That’s where he, a world famous gynecologist, works.
In America, hospitals are not hierarchized. Each hospital is to meet the basic medical needs of common people. Doctors all over the whole country are doing the same thing in clinical. The American College of Obstetricians and Gynecologists (ACOG) releases guidelines for all the obstetrician-gynecologists to follow. Similar comprehensive guidelines are also available in other specialties, such as neurology and oncology.
Medical personnel training system
The more I learn about America’s medical system, the more I admire to the rational training system established for over 100 years. The current residency program goes back to the year of 1893 when the Johns Hopkins University School of Medicine (JHUSOM) carried out the residency program. The program was soon systematically introduced all over America, keeping up till now. Wanting to become a doctor in America after medical school? Graduates should participate in the National Resident Matching Program (NRMP) (or the Match) to get a chance of four years’ residency program. Only pass the medical licensing examination after the residency program, can you become a qualified doctor. Being a residency does not make a permanent job. Actually, there are three choices after the residency program: finding a job in medical institutions; opening your own clinic, participating in the fellowship training for 2 to 5 years for further study and finally becoming an expert in a specific field.
Glancing back over our domestic situation, I think we still haven’t established a training system for young doctors yet. Take me for example, having been working for 15 years in the Department of Obstetrics and Gynecology in Peking Union Medical College Hospital (PUMCH), I took about ten years to become an independent surgeon. While in America, this progress is accomplished during the 4-year residency program. In PUMCH, the patients swarm on experts, all the medical systems are seemingly established around the experts. Residents are not actively involved in the diagnosis and treatment, only helping to write medical records.
Mobility of staffs
Medical staffs seldom change their working units in China. Once signing with a hospital, one would work there for the rest of his life. Under this system, a doctor’s professional competence hangs on the standard of the hospital he works in. Standards of hospitals vary considerably, and so does the doctors’ competence. Moreover, there is no uniform standard for the same disease among hospitals.
After seeing the outside world, I realize the major cause of the health gap between China and America is our medical professional training system. European countries and the United States had established a well-developed physician training system as early as the beginning of the 20th Century. China may be one of the minorities who still have no rational residency and specialist training program when looking around the world. For Chinese doctors, the most critical access threshold is the examination for the qualifications of medical practitioner after obtaining a bachelor’s degree in medical school. However, Chinese doctors lack of professional practicing and are not required to attend various departments to build up a good stock of clinical experience like doctors in most other countries. So it’s not rare to see Doctors of Medicine don’t know how to see the patient.
Although Shanghai has been executing the residency rotation program under the deployment of the competent department of health since 2008, and so do Beijing, Guangdong and Hunan, we must face the truth that the residency are still not eligible to independent work even though they have taken three years of training. I’m afraid to say that what they have learnt during the three years are only writing a case report, prescribing tests, dragging hook and doing some simple operation. Even though taking part in clinical work, they will not substantially enhancing the hospital they work in.
As for the health care gap between China and America, e-pal “sxwsf” considers it relies on different values between Chinese doctors and foreign doctors as well. It’s true that Chinese are always shorted-sighted, but they can’t get by if they don’t have prescription privileges during the residency rotation program. In addition, marginalized doctors are hard to pursue their academic value, no wonder that no one wants to go to the grass-roots.
Where to go
It’s quite necessary to establish a national residency program after absorbing the essence of other countries.
Besides, doctors should be admitted to work in different institutions. The key responsibility for public hospitals and experts should be teaching, focusing on training of qualified doctors. Meanwhile, make sure that the experts can work in private hospitals or their own clinics to fulfill themselves following the rule of market besides their training responsibilities. Therefore, I agree with the idea that special medical care should be merely available in private hospitals but not in public hospitals.
Thirdly, we should stop hospital level accreditation. The current accreditation has induced patients to pursue high quality medical resource. Instead, patients are encouraged to easily find a well-known expert in any clinic or hospital.
Finally, we’d better abandon surgery classification included systems limiting the development of hospitals. The initial intention of the system is to ensure the medical safety, however, looking around; we find if only there are qualified certificated doctors, it’s not important for which hospital to perform the operation. Private hospitals and community hospitals should be permitted to carry out difficult operations as long as the hospital has conditions and the doctors are qualified, just like we see the top expert operating in a Chattanooga community hospital.
Some e-pals also have some suggestions. E-pal “xgrmyy4083” thinks that the government should invest more on medical reforms, and integrate the medical resources of public hospital at the grass-roots. Besides, it’s good to introduce more flexible policies to import sophisticated talents to the grass-roots, and to definitely, but not seemingly, standardize the residency training program, especially for doctors from the grass-roots. Another e-pal “mjp008008” says that it’s too difficult to fulfill experts to work in county hospitals. It’s not something about the medicine, but about the thoughts deeply rooted within us. No matter which industry it is, the majority expect the levels in big cities are much higher: villagers think county’s levels are higher than themselves, while the counties consider cities are higher, cities suppose provinces higher, provinces believe Beijing or Shanghai are higher. There is probably no fundamental change at all if we insist on our regional prejudice.
All in all, reform means redistributing benefits. It’s time for PUMCH, the founder and witness of modern medicine in China, to seek changes: how to build a medical training base for others to follow; how to make the residency, graduates and trainee doctors eligible to work independently after training. Only constantly export qualified talents to the national medical market, can we solve the health care difficulties common people experience. I do hope that one day, people can find satisfactory qualified doctors beside them, but not in PUMCH thousands of miles away.
Disclosure: This article is originally published in cn.nytimes.com which authorized the journal to translate and publish it in English.