Hello!  I have compiled my thoughts on the Cornell University and Zhejiang University neurology exchange experience so that others may understand my perspective on the similarities and differences between the medical system and culture at NewYork-Presbyterian Hospital and Sir Run Run Shaw Hospital.  I am very thankful for this experience. 

Basic outline:

1.  Medical education process and system in China versus the U.S.

2. Culture of medical student and resident training

3. Perception of doctors by public and doctor lifestyle

4. Medical Practice similarities and differences

5. Patient Etiquette and Culture

6. Need for increased collaboration and exchange between both countries

The U.S. medical education system seems to be more uniformly structured as there is usually only one pathway to becoming a physician (MD/DO Program) versus China where there are combined undergraduate/medical programs of 5, 7, and 8 years long.  To become a doctor in the U.S., a person will go to undergraduate university for four years and select a concentration or “major” to focus their study.  For example, a person can choose biology, neuroscience, or English, etc. as their major or concentration in college.  These students are considered “pre-medical” students and they need to take a list of required courses in order to apply for medical school.  These students must also take a national examination called the MCAT (Medical Computerized Assessment Test) in order to apply to medical school. 

After getting into a U.S. medical school, the student will spend four years learning medicine either in a systems-based curriculum (e.g. cardiology, pulmonology, etc.) or a more traditional subject-based curriculum (pathology, histology,  physiology, etc.).

After four years of medical school, a person will select what type of doctor (specialization) they want to become.  The American College of Graduate Medical Education (ACGME) certifies residency programs in the United States and students can choose to specialize in either medical or surgical specialties.  Residency programs range from 3-8 years with medical type residencies being the shortest and surgical type specialties taking the longest time.  Usually the first year of residency includes an internship year in which the person works either in general medicine programs, general surgery programs, or transitional year programs which allow the student to rotate through many different medical specialties. 

After residency, doctors can either choose to become a fellow (1-2 years long generally) or become an attending and work in a hospital.  If a person does not take any breaks between graduating high school and finishing medical training, the average age of a starting attending is around 32 or 33 years old.  

From what I’ve learned in China, medical training as of 2016 is more heterogeneous as people can become doctors by either a five year, seven year, or eight year program.  This includes what Americans consider both undergraduate and medical school education.  Generally, academic hospitals in China prefer accepting doctors who have done seven or eight year programs that are similar to that of the U.S.  In the villages of China however, it seems as though training may be less formalized and doctors may practice without a license.  Doctors from 5 year programs can be accepted into these village and town hospitals.  Though practice at this level of training is generally not accepted in the U.S., in China, more rural areas depend on these kinds of doctors to care for their patients since there are too few doctors in China per patient, which may be a more dire situation in China compared to the U.S.  I’ve seen this in the clinics at Sir Run Run Shaw Hospital (SRRSH) as doctors will see as many as 20-30 patients in one afternoon, spending about 5-15 minutes on each patient.

U.S. and China:  Medical training in the U.S. also seems to be more organized and resident-driven.  Most of the time in the U.S.  attending physicians want residents and fellows to analyze problems critically and independently come to decisions regarding the care of their patients.  I also see that in the U.S., the residents are in charge of responding to neurologic emergencies such as strokes and seizures whereas from what I’ve observed at SRRSH, the first responders seem to be neurology fellows or even attendings who are on call.  The Chinese doctors I have spoken to have said that this is because they want to make sure that the patient is not harmed by resident decision-making however in the U.S., residents responding as the first-line responders is the norm; this is expected given the fact that this arguably accelerates learning in order for a resident to eventually become an independent attending. 

Overall, the U.S. system of medical training seems to require autonomy of practice at a faster rate than China.  I learned that in China, fellowship does not necessarily last only 1-3 years as it does in the U.S.; rather a fellowship may last for more than 3 years, depending on whether or not a fellow meets the expectations of becoming a fellow, including publishing scientific and clinical articles. 

I also see that the time of interns and residents seems to be more protected in China compared to residents in the U.S.  The interns tend to have the weekends off in China however the residents in China work 6 days a week as in the U.S., but do not seem to take overnight call.  They also do not take consults in SRRSH; rather the consults are given to the on-call attending physicians.  The medical students at SRRSH also often times have time for lunch and a short nap following lunch which is not commonplace in the U.S.

I have also noted that the prestige associated with being a doctor in China seems to be less than that of the U.S. per the report of some Chinese doctors; doctors in China also get paid at a lower salary compared to doctors in the U.S. despite a narrowing gap in cost of living between places in China and places in the U.S.  The attending physicians who are long established seem to make a salary equivalent of that of more senior residents and fellows in the U.S.

The U.S. as expected seems to have more in terms of medical resources and thus residents and attendings in the U.S. tend to order more tests and exams in the U.S. compared to their Chinese counterparts where resource allocation is often times considered more greatly by Chinese attendings and residents.  This is in spite of the fact that exams ordered in China are at a fraction of the cost of that in the U.S. despite being the same test (e.g. the MRI machine used in SRRSH is the same machine used in most American hospitals). 

Insurance is also simplified in China where the government provides insurance to all people and covers for the basic medical necessities of the people whereas there are still a substantial amount of people in the U.S. who are still without insurance.  The insurance system in the U.S. is complicated by a myriad of private insurance companies and subgroup public insurance groups that often times requires prior authorizations for different treatment regimens.  People in China also seem to have less pushback in terms of tests being rejected by insurance, an observation I made while I was in clinic in SRRSH.   The U.S. also seems to have much more work in terms of medical documentation in the medical record.  The attending in the SRRSH clinic writes a very cursory note on the electronic health record and spends most of the clinic time talking to the patient versus typing at a computer, though in China, the amount of patients that have to be seen in any given morning are about two to three times more than that of the average clinician in the U.S., allowing the Chinese doctors to see patients on average about every 5-10 minutes versus the U.S. where clinic patients are seen about every 30-40 minutes. 

The culture of patient confidentiality is also very different in China versus the U.S. In the ward and clinic, I was surprised to see other patients other than the patient him or herself listening in on our conversations with our patients.  This is a very different cultural experience versus the U.S. where patient confidentiality holds an almost sacred position in American medical practice (HIPAA and HIPAA violations).   This may reflect the overall cultural sentiment that in China, the Chinese people are more of a homogenous community that shares information within that community rather than a group of separate individuals from heterogenous backgrounds. 

I also saw a very different culture in terms of patient etiquette.  In China, patients seemed more aggressive in approaching the doctor versus in the U.S. where patients may disagree with the doctor, but often times in a non-aggressive way.  The patients at SRRSH would at times push the clinic door open to talk to the doctor in spite of the fact that the doctor was busy seeing another patient.  This type of behavior is not common in the U.S.  It was also noted by stories from the doctors at SRRSH that the reports of violence against doctors in China are true.  Compared to the U.S. which at times has overly legalistic involvement in medicine, Chinese patients take a more grassroots approach to their medical complaints.  When not satisfied with their medical care, they do not resort to use of lawyers, but rather argue with the doctor and even physically hurt the doctor or possibly appeal to local media to shame the doctor and the hospital for sub-par medical care.  The Chinese government does not often step in to stop these acts.  The reports of doctors fearing for their lives are indeed true per the doctors I spoke to at SRRSH. 

I also observed that there seems to not be a scheduled time in many hospitals for patients to see their doctors in clinic; rather, the model of the walk-in clinic is more prevalent in China versus the U.S.  Also often times when a patient comes to clinic, the whole family will often accompany that patient rather than in the U.S. where at most one family member usually accompanies the family member.  Also at times, a patient at SRRSH would self-discontinue his or her medications under the false belief that since they no longer had new symptoms, they do not need to take any prophylactic medications (such as the case for statin and aspirin use as secondary ppx for stroke). 

It was also noted that unlike the U.S., public hospitals are preferred and trusted compared to private hospitals and in fact public hospitals are regarded as the top hospitals in the country versus private hospitals. This is slowly changing however as private hospitals are continuing to improve in terms of quality. 

In terms of palliative care, speaking with one of the doctors here, the family seems to drive decision making in terms of final wishes versus the patient him or herself.  The doctor has to reach a consensus with the family rather than with the patient as to what needs to be done for a terminally-ill patient. At times, the family may even request that the doctor not tell the patient his or her diagnosis or prognosis.  This is very different from the U.S. where it is largely believed that the patient should drive decisions.  The concept of patient-centered care in the U.S. has an analogous system in China which I like to call “family-centered care”. The family and even at times, the patient’s community will help mak9e medical decision for the patient, a structure that is observed in the more communal decision-making process of China.  Whereas the U.S. seems to pride itself on the power of the individual, the Chinese may focus more on the power of the community and communal decisions. Harmony and agreement seem to take precedence to liberty and freedom of individual rights in China. 

Perceptions of depression and anxiety seem to also be perceived differently in China versus the U.S. It is often a shameful thing to admit to family members that a person is depressed or has a mental illness whereas it is more socially acceptable to tie mental dysfunctional symptoms to somatic complaints such as body pain and fatigue. 

I was also very surprised that though traditional Chinese medicine is often times present in the hospital as a separate department, it seems that Chinese doctors who are trained in allopathic medicine do not support use of this treatment modality as a primary means to treat disease since such use of treatment often times lacks scientific evidence.  Doctors at SRRSH prefer to look for evidence-based treatment when taking care of their patients and actively search for the latest literature to care for their patients. 

All in all, I am very thankful for this opportunity to be in China and have many more observations about the medical system here that have helped me understand how to better care for my Chinese immigrant patients in New York City.  I noted that there are indeed many similarities in how medicine is practiced in SRRSH vs. NYPH Cornell and I think that it would be a great idea to start a telemedicine program in which clinicians from both institutions regularly kept in touch with each other to present cases and share clinical data for potential future research.  There is a need for this as China is a developing country that is growing at a rapid rate and has much to offer the U.S. in terms of how to practice in resource poor settings.