February 17, 2011
We saw 70 patients in one afternoon today in general neurology clinic. 70 patients, one attending and two students fresh from the basic science lab where Chinese medical students seem to spend most of their time. It was controlled chaos.
Some patients traveled all day from neighboring provinces including Hunan and Guanxi to come to clinic while others lived just blocks away. They lined up before dawn, even as early as the night before, in order to get a number that would allow them to be seen by the doctor before the clinic doors closed. Their patience, lack of any sense of entitlement and adherence are remarkable and lay the groundwork for the patient-physician relationship (although later I find out that the physician I am working with and the time she takes to build relationships with her patients are unique in China, atypical of the mindset of many other Chinese physicians, and thus the adherence of her patients is unusual for most Chinese patients). They are grateful for what she does for them, even in the average 5-minute encounter, and they work hard to follow her orders within the limitations of social, financial and cultural barriers.
The clinic is a microcosm for the rest of China, at least what I’ve seen in my short time here on this trip: overbooked, overcrowded, overwrought and overwhelmed. No matter where you go, there is no respite from the throngs of people in this city. I’ve been to some of the biggest cities in the world on most of the continents, but I still cannot get used to the scale of the population here, as millions push and shove their way past me in an attempt to get a seat on the subway or to clear a path up the stairwell. I am unaccustomed to this mindset of having to compete so hard all day, every day. I wonder what would happen if all billion plus people decided to wait in line instead of pushing their way to the front.
That the same holds true in the clinic, in the place where the masses come for medical care, should not surprise me. In a way, the fact that patients return week after week is a testament to the value placed on health prevention in certain aspects of the Chinese medical system and to the trust that patients place in the physicians who are willing to take the time to build a relationship, despite their unwavering attachment to Chinese herbs and cocktails of roots and other unidentifiable ingredients, some of which likely do have benefit. In another sense, the overbooked clinic underscores the weaknesses in the system. Most patients have to return weekly or bimonthly in large part because the Chinese government won’t allow physicians to prescribe more than a week or two of medications at any given time. Physicians’ salaries are docked if the amount of medication prescribed is out of proportion to the number of revenue-generating examinations ordered. No different from in the United States, the really special physicians that I’ve been working with have tricks up their sleeve to try to get around these restrictions. They often write multiple prescriptions for the same medication and instruct patients to have them filled outside of the hospital pharmacy. It’s more difficult, though, to game the system in the inpatient setting where, when the cost of a patient’s stay exceeds the limit covered by insurance and the patient cannot or is unwilling to leave the hospital, the hospital will take what is needed to pay for services out of the attending’s salary.
In a country with such intellectual prowess and value placed on scientific and medical progress, it remains stunted by the policies of the government. For example, it is illegal for patients to go outside of the country for certain medications that cannot be obtained in China, even if they are readily available in easily accessible neighboring cities such as Hong Kong. It is also illegal to send blood samples out of the country for laboratory testing, even for research purposes. On the other hand, the power of a totalitarian government, if applied in ways that benefit the people, is pretty astounding, an example of which I will visit later this week in a small town outside of Guangzhou where the government has spent over 20 years cultivating one of the strongest and most successful chronic disease prevention programs in the country.
There is an upside to requiring patients to return to the clinic with a frequency that we would never, could never accommodate in the United States. The model is akin to “weekly observed therapy” but instead of sending out health care workers to locate patients in far-flung corners of the world’s most populous nation, we’re lucky enough that the patients come to us, week after week. Some patients have literally been seen every week for nearly 10 years since their stroke, now transformed into a walking advertisement for secondary stroke prevention with perfect blood pressure, lipid and diabetes control.
For most of the patients who are follow ups, like speed-rounds, we take 1.5 minutes to review symptoms (“Any new stroke symptoms, any seizures, how’s the headache?”), 1 minute to do an abbreviated version of medication reconciliation as we root through the bag of medications they’ve brought in, discarding those that they should not be taking, 30 seconds to take their blood pressure, 30 seconds for a breezy neurologic exam and then 1.5 minutes of scanning any new labs or other studies and then counseling before calling for the next patient. By seeing patients on a weekly basis, blood pressure control, for example, becomes a precise science, very different from when we see stroke follow up patients in neurology clinic once every few months, at best.
(Not surprisingly, there is no privacy in clinic. Despite valiant efforts by the medical students to maintain crowd control, patients and their families hover over us as we see patients. We ask about bowel function and sexual dysfunction with more than 20 people looking on. I keep looking for a curtain to draw but there isn’t one.)
As with everything in China, the question remains as to how to disseminate the practice of health promotion and disease prevention beyond the clinic doors of a few very special and wise physicians, primarily located in the large cities. Strolling down the glittering streets of Guangzhou where China’s rapid development and growing wealth are apparent, the widening gap between rich and poor is hard to miss. Caring for all of this country’s patients, a billion strong, will be one of China’s most formidable public health challenges in the years to come.