BY ANSON WANG
Surgeons and nurses perform a heart transplant surgery on a 30 year-old woman. The team has just placed the new heart into the chest cavity. Surgeries can last anywhere between two to five hours, and surgeons often work late into the night. The team includes Dr. Huang and her colleagues.
I brushed open the long plastic curtains that covered the main entrance to the emergency room of Fuwai Cardiology Hospital. It was another warm and humid day in Beijing in the middle of June, or what the residents called, “sauna weather.” The waiting area of the emergency room was even hotter, and the walls of the hospital offered no solace from the noises of the crowded intersection of the two main roads outside. Families were crowded into the waiting room, occupying all the seating and floor space that the hospital provided. The buzz of noise and conversation made it difficult to decipher any single voice. As I passed through the emergency room, the first thing I was struck by were the beds; more than 50 mobile cots and stretchers crowded the emergency room and an additional area behind the main waiting room. Nurses dressed in pale-pink scrubs ran back and forth attending to these patients, administering IVs, or plugging in wires to EKG machines. As I snaked my way in between patients and their families, I imagined the austere waiting rooms of hospitals back in my hometown in New York, silent except for the corner television playing reruns of daytime television.
My path through the labyrinthine hallways of the hospital was constantly interrupted by a frenzied family or a blur of white or pink as doctors and nurses rushed by on their way to see another patient. Like looking into the windows of a passing train, I caught fleeting glimpses into some of the patient rooms. Without exception, the rooms were packed with families and beds, with some crammed against the walls and separated only by a few chairs and a white metal nightstand filled with medical equipment. In the outpatient lobby, scores of people crowded in front of check-in and pick-up windows in lines that were vaguely defined only by the direction that each person was facing. If signs were not present to label each room, one would think he or she might have just walked straight into the middle of the New York Stock Exchange.
I was in the hospital for two specific reasons. The first was that my grandfather was experiencing complications due to heart failure, and was being evaluated by the doctors of Fuwai for a few days. The second was that this was my first day – and my first time to shadow – a clinical physician. I was extremely curious about how China had adapted its medical system to accommodate its massive population and eager to witness this firsthand. (Just for perspective, China’s population currently exceeds 1.3 billion, and the city of Beijing alone contains roughly 21.5 million residents, which is almost twice the size of New York City and Los Angeles combined.)1
Fuwai Cardiology Hospital sits on the west side of Beijing within the Second Ring Road, the innermost of a set of concentric highways that define the cityscape. Founded in 1957 as a hospital specializing in cardiovascular disease, it stands as a symbol of China’s relatively recent modernity. Currently, its mix of concrete Soviet-style and modern industrial buildings make up a 570,000 square foot facility that employs roughly 3,000 medical workers and supporting staff. For the citizens of China, Fuwai stands as a beacon of hope for those suffering from the rarest and most serious cases of cardiovascular disease. Due to its reputation as one of the leading institutions for cardiovascular care in Asia, patients fly in from all over China to be seen by China’s most qualified cardiologists and surgeons. In 2014, Fuwai treated a total of 470,658 patients, an average of about 1,300 patients per day, according to its cardiovascular medicine outcomes report.2 Despite having familiarized myself with these figures, and having visited Beijing on multiple occasions, nothing prepared me for the overwhelming patient per square foot phenomenon that confronted me as soon as I stepped foot into the hospital. Yet, the number of patients treated at Fuwai hospital has increased by 174% since 2007 and this number continues to rise.
Despite this steady increase in hospital bed occupancy, which reached as high as 105% in 2014, and an increase in the number of interventional therapeutic procedures performed per year, inpatient mortality and average hospitalization days have steadily declined over the last 6 years, and have reached lows of 0.18% and 5.1 days respectively in 2014.
How does Fuwai accommodate its increasing patient volume, yet continue to maximize treatment outcomes?
It involves addressing social as well as medical factors of heart disease. Overall health in China is continuously affected by three dominant social factors: the growth of cities, the rising socioeconomic status of its residents, and its massive, aging population. These factors all have profound effects on cardiovascular health. Currently, heart disease is identified as the second leading cause of death behind cancer, accounting for 21% of all mortalities. As more of China’s citizens live longer, improve their standard of living, and grow older, the incidence of cardiovascular disease is likely to continue to grow. As the pinnacle of cardiovascular care, Fuwai Cardiology Hospital not only offered me an opportunity to see a multitude of patients and the afflictions that ailed them, but it also served as an insightful window into China’s most crucial issues in health in its most extreme cases. With each day that I spent observing the physicians carry on their duties, I learned more about the Chinese health system, its culture, and insights into how medicine adapted to one of the world’s most populous nations.
DAY 1
Dr. Huang was sitting in the transplant office when I entered. The room was cluttered with patient files, eating utensils, and file cabinets. Medical cabinets against the walls housed everything from gauze to IV needles. In the corner of the room was a bunk bed, most likely for anyone working a late night shift in the ward. The office was used by three other physicians as it was the center of all operations that took place on the floor. Dr. Huang was an old colleague of my dad’s back when he used to work in Fuwai as a researcher. She greeted me with a smile and led me to her private office as we chatted about how busy the hospital seemed today and how tall I had grown since the last time we met. Her office was a cozy space, located between the surgical and intensive care wards. Shelves against the wall displayed extensive collections of manuals and journals.
Dr. Huang was an internal medicine physician specializing in cardiac transplants. She was in charge of prescreening patients for transplants and recommending and preparing procedures. She was a very tall woman, around my own height of 5 foot 11 inches, with short curly black hair and a face that radiated with excitement whenever she smiled or joked about her work. She also loved to chat, and could easily carry a conversation by herself. “Let’s go check up on your grandpa first of all, how about that?” she said, before leading me back downstairs.
With only five patients sharing his room, my grandfather’s room on the first floor was considered one of the more spacious available. Before he was admitted, he had put up a huge fuss about staying overnight in a hospital, but reluctantly gave in to the pleas of my grandmother and father. After spending no more than half a day in the crowded halls, I could understand his complaints. Even in his room, the lack of privacy surrounding patient care was apparent. Dr. Huang conducted her physical examinations and interview of my grandpa in the open view of other patients and their families. In the United States, patient confidentiality is as sacred to medical care as Sunday mass is to the Catholic faith. No one seemed to mind though, as recovery and treatment seemed to be everyone’s number one priority. After all, how could you afford privacy in such crowded conditions?
DAY 3
By the third day I had grown accustomed to the crowded conditions. It was easy to see why there were so many patients. In China, diagnostic and therapeutic care – even in an area as specialized as cardiology – do not require referrals from a primary physician. As a result, any family can walk up to a check-in window in the outpatient lobby and queue for consultation by a cardiologist. If they were unable to obtain a consultation here, many families turn to emergency services since, by law, the emergency room is required to see every patient that requests care.
Today, I followed Dr. Huang into the emergency room as she made her rounds with her patients. The case we investigated seemed strange, an adult in his mid-twenties reporting symptoms of heart failure and fatigue. He was a portly man, lying sideways on bed number 6 in the corner of the room while playing games on his Samsung Galaxy. His mother and aunt stood nearby, clearly more concerned with the situation than the patient himself. Dr. Huang wasted no time in gathering a comprehensive medical history.
“Does he drink?” she asked the mother.
“Only in moderation, he drinks a few times a month,” replied the mother, looking at her son with a grave face. Her accent gave away that we was from the southern region of China, and her expression betrayed a hint of shame.
“How much do you consume when you drink?” asked Dr. Huang to the man, still lying sideways.
“Maybe a beer…or half a bottle of Er Guo Tou,” he admitted. Er Guo Tou is China’s famous white rice wine, which can sometimes contain up to 60% alcohol.
Dr. Huang addressed the mother sternly and scowled at her for concealing the truth. The man continued to reveal that he drank several times a week and consumed more than the average human should to maintain a healthy living. Dr. Huang threatened that if things were to continue, he would need a heart transplant. I was stunned; how could she be so harsh to a patient? What ever happened to good bed-side manners?
“They don’t listen! Patients think they always know what’s best for themselves, or they think they can get better on their own. They’re stubborn folk, and they sometimes don’t trust what you tell them. You need to be stern and confident to communicate to a patient successfully,” explained Dr. Huang. It certainly came across in her sharp tongue and rapid-fire manner of speaking. “But fortunately, they are usually pretty cooperative. They understand that their life is in your hands, and they will do anything to ensure the best of care.”
As I learned later from conversations with patients and other physicians in Fuwai, clear communication of the role of patient responsibility is invaluable, sometimes as a recusal of the doctor’s role in the case of poor outcomes. Chinese families will accept nothing less than the best when the health of their loved ones is concerned, and this sentiment can sometimes take a deadly turn. Reports of doctors being beaten, sometimes to death, by dissatisfied families are far too frequent in Chinese media. According to a report by the Chinese Medical Doctors’ Association, more than 70 percent of physicians surveyed have suffered verbal abuse or physical violence from patients, and 13 percent of doctors and nurses have reported physical injuries. Some say this “patient-doctor conflict” is the result of a broken health system, one that overworks and underpays its doctors, and leaves hospitals and families struggling to pay for care. Others blame social prejudice of doctors that often paints them as civil servants rather than specialists in a highly trained and professional field.3
Prejudice about physicians also involved traditional gender roles. I had many conversations with family members regarding my desire to be a physician. It’s a tiring path, they would say, but rewarding and fitting for a man. Not for a girl though, it’s too stressful; girls should grow up to be teachers.
DAY 5
Families were already lined up in front of the door leading to a small examination room by the time Dr. Huang and I arrived for work at 7AM. We were seated behind a large metal desk as patients filtered one-by-one into the room to consult Dr. Huang concerning the symptoms that discomforted them. One family I spoke to flew in all the way from Xinjiang, a province located in the westernmost area of China. The complaints frequently were related to symptoms of heart failure or coronary artery disease. Occasionally, a patient’s condition had deteriorated so severely that combination drug therapy provided no further relief. “There really are no other options that can help you. Have you considered changing a heart?” Dr. Huang dropped the news like a cannon ball falling through air. In the United States, the news of a heart transplant would have been handled more delicately. It was surprising how calmly the patient and his family received the news, as if they were already expecting to hear it.
DAY 10
During my second week, I was allowed to observe Dr. Huang and her team perform a heart transplant surgery. I was informed that the hospital performed two or three heart transplant surgeries a day, depending on the rate of delivery of donor hearts. The surgery was performed late at night. I dressed up in scrubs and disinfected myself before entering the operating room. Machines and monitors were laid out neatly, all connected by tubes to a figure on a table covered by a green sheet, which I presumed was the patient. The donor heart had already been placed in the chest cavity, and the surgeon was busy connecting all the necessary arteries and veins. I stepped up on the viewing platform which was right next to the patient. The surgeon made conversation with me, but I only dared reply in short phrases. I feared that one wrong word could lead to a slip of the hand, and before I knew it I would have a medical malpractice lawsuit before even reaching medical school. The surgery was fascinating to witness, yet I was the only anxious person in the room. After returning to Dr. Huang’s office, I took the stairwell where I found the patient’s family sitting on foam mats and plastic stools. They immediately stood up upon seeing me, as they’d seen me walk around the hospital with Dr. Huang.
“How is she doing?” her mother asked me, her eyes filled with hope and fatigue. I replied that she was doing fine, and that they had just finished the transplant. I reassured her mother that the patient’s new heart was beating fine on its own. The mother and her sister breathed a great sigh of relief and thanked me for my help. I sheepishly said it was no trouble at all, and continued down the stairs. I believe that moments like this are common to all physicians across the world, regardless of their medical systems. It was a moment that reaffirmed my desire to enter the medical profession.
As a leading institution in the diagnosis and treatment of cardiovascular diseases, Fuwai offered a unique perspective into the effects of the Chinese health system, one that relies very crucially on efficiency in order to treat the sheer volume of patients requiring care per day. In an age where health care in the United States faces criticism as a business and calls for better efficiency, lower costs, and shorter hospital wait times, it may be best to turn to other nations to observe how they do it differently. In a nation that is increasingly business driven, it seems only natural to turn back to the numbers. Perhaps health is simply about maximizing the number of patients that are seen and treated by medical professionals, and insuring that these patients recover. As the most populous nation on Earth, China demonstrates that even at extraneous numbers, health care is still possible. We must reflect on the efficiency of our own health care, both from the perspective of individual doctors, to the system as a whole.
Anson Wang is a junior in Davenport College. Anson is a Molecular Biophysics and Biochemistry major from New York. He can be contacted at anson.wang@yale.edu.
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References:
- CDC in China. (2014). The Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/globalhealth/countries/china/
- 2014 Outcomes. (2014). Department of Cardiovascular Medicine, Cardiovascular Institute & Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Center for Cardiovascular Diseases.
Wang, X. (2015). Doctors face verbal abuse or violence. Chinese Daily. Retrieved from http://www.chinadaily.com.cn/china/2015-05/29/content_20852488.htm
Yale Global Health Review 