Conversations at the top of the world: ACPE delegation travels to China and Tibet.

1.3 billion people.

22 percent of the world's population.

The fastest growing economy in the world--average annual growth rate of 8 percent during the past 25 years. (1)

Host of the 2008 Summer Olympics.

The prominence of China as one of the most interesting and vital countries in the world--and an opportunity for an adventure in leadership--was the draw for a September 2005 trip for 47 ACPE members and/or guests to Beijing and Chengdu in China and Lhasa in the Tibet Autonomous Region of China.

People to People Ambassador Programs of Spokane, Wash., was interested in sending physician executives to China on a professional and cultural exchange, consistent with founder Dwight Eisenhower's goals of promoting greater understanding among nations by allowing people to meet with each other.

Celebrating its 50th anniversary, People to People approved a stop in Lhasa, Tibet for our group--a rare treat for Americans. Politically sensitive and located at 12,500 ft. elevation, Lhasa posed more than a few challenges.

The delegation's goals were to:

* Learn about the structure, financing and delivery of China's health care system.

* Gain an understanding of traditional Chinese and Tibetan medical practices.

* Establish professional and personal connections with our Chinese hosts.

* Learn how each of us would deal with unfamiliar situations and circumstances--an opportunity to develop useful skills for our careers.

Looking over the list of delegates prior to departure, it was apparent that the travelers were highly accomplished physician leaders. As delegation leader, I wondered about group dynamics and my ability to contribute to a worthwhile experience for jet-lagged travelers in a very foreign country.

Although familiar with the Himalayas and Asia from prior travels, I had never been to China or Tibet, never led a delegation before, and knew that the altitude of Lhasa would be challenging for all of us.

Far East arrival

5:30 am--Hong Kong International Airport.

Almost all of the delegates and guests arrived on the same flight, in a mostly deserted airport. As the sun was coming up over the mountains, we gathered to get acquainted and set expectations for ourselves.

In our initial introductions, we asked the delegates and guests to answer only three questions: What is your name? Where are you from? Why are you on this journey?

Using the metaphor of a mountain climb, we talked about how each of us was on the same rope for the next 12 days and nights, with the success of the delegation dependent upon how we worked and communicated together. Our expectations included possible uncomfortable situations, flexibility with changing situations and the need to support each other when the occasion required.

In retrospect, this meeting was critical to the outcome of the journey.

Communism and capitalism

Meeting with officials of the Chinese Ministry of Health and the Chinese Medical Doctors Association in Beijing, we learned that the social and governmental systems are "communist, with Chinese characteristics."

Those Chinese characteristics include entrepreneurialism, optimism for the future and a profound work ethic among the Chinese people that was evident at each of our stops in three cities.

The physicians we met with shared the characteristics of our colleagues here in the U.S.--they have genuine concern for their patients' ability to get access to the care they need and they recognize the dilemma of providing comprehensive, high-cost treatment in an environment of limited resources.

Like the U.S., a large percentage of China's population is uninsured (about two-thirds). In addition, many are underinsured for "big sickness" such as cancer, stroke, and other life threatening diseases. (2)

From 1978 to 2003, the government's share of health care spending has dropped significantly, so that current out-of-pocket contributions have risen to around 60 percent from 20 percent. (2)

Also similar to the U.S., catastrophic illness is often a cause of bankruptcy in China. With minimal government financing and oversight of health system utilization, capitalism dominates health care transactions--a surprising finding in a communist country!

For example, according to the Wall Street Journal, physicians in Shanghai can double their monthly government pay of less than $400 by prescribing tests and drugs with high profit margins. Hospitals in Shanghai see 45 percent of their revenues from drug sales. (2)

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We consistently heard that life was much better than 10 or 15 years ago. "Chairman Mao was a great leader. He did many great things. And he did some things that weren't so great," was a phrase that was repeated many times by our guides.

We learned that the health system is undergoing transformation to meet the growing needs and demands of both rural and urban populations. To address the social stability of the country arising from rapidly escalating health care costs and out-of-pocket expense, the government is trying to expand state insurance coverage for both urban and country dwellers. It is also setting up networks of community health centers.

With close to 60 percent of health care costs borne by the consumer, there is a booming industry in traditional Chinese and Tibetan medicine, perhaps because the concepts and experience have met with success, or perhaps because it is a cheaper alternative to high-tech interventions.

Traditional approaches to health care were woven into the facilities well known for their adoption of Western medical and surgical therapies, such as the Peking University Medical Hospital in Beijing.

At the Traditional Chinese Medicine University Medical School and Hospital in Chengdu, we visited the pharmacy, which resembled an agricultural feed and seed supply store. The medications prescribed are plants, herbs and minerals. We also took note that the costs of visits, treatments, and procedures were posted in the lobby on an electronic billboard--another symbol of capitalism in health care.

Patients often choose to visit popular physicians with reputations for excellence, rather than receive care from a local physician. This has created long waits and queues in some of the urban medical centers. Many physicians supplement their government salaries with payment from private patients, in addition to the prescribing incentives.

Physicians are the administrators of China's hospitals. Our host physicians--usually the highest ranking physician executives of the hospitals we visited--were anxious to hear more about the American College of Physician Executives, and how we might be able to collaborate.

In fact, we have shared The Physician Executive journal and course announcements with several of our host physicians. In the future, we hope some Chinese physicians can attend one of the ACPE Institutes, and perhaps give a special presentation on some aspect of health care in China or Tibet.

"We are looking forward to more communication with ACPE," said Yin Dakui, one of the Chinese hosts. "We need to address common issues such as patient security, training of the doctors, and the quality of medical care."

Old and new

Traditional Tibetan medicine focuses on environmental factors as etiologic components of disease. Those factors are

* Earth

* Water

* Fire

* Life energy (Chi)

Likewise, the human biological response can be classified similarly, with

* Musculoskeletal (Earth)

* Blood (Water)

* Temperature and respiration (Fire)

* Emotions (Chi)

These are the focus of diagnosis and treatment. Great attention is paid to when, where and how traditional medicines (derived from plants, animals, and minerals) are administered. Astrological charts are often consulted to determine best times for treatment.

Prevention of illness by proper diet, activity, massage, lotions and pharmacotherapy is strongly advocated. We heard that emerging health problems include anxiety-related arrythmias and other disorders correlated with the increasingly fast pace of life in Tibet.

Unfortunately, there are few English translations of the concepts of environmental and biologic balance used in traditional Tibetan medicine.

At the Tibet Medical College, we were given the opportunity to visit the medical library. The medical texts are stored in long, narrow, glass-faced, wood-framed storage compartments, appearing exactly like the Buddhist scripts at the monasteries.

We were amazed when the librarian took one of these ancient texts--dating to the seventh century--out for us to page through! She pointed out that the perfectly preserved Tibetan Sanskrit was written on bark from a plant known to be poisonous to all insects, hence the remarkable condition of the text.

Recent visitors to China are impressed by the massive number of construction projects in cities and rural communities. At several of the hospitals we visited, new buildings were being erected by the "national birds of China"--construction cranes. Despite the new facilities, CT scanners, MRIs, and endoscopic equipment were older models, purchased used.

With the growth of the Chinese economy, the middle class is rapidly expanding and upper income Chinese are seeking improved access to health care, and more technologically advanced care.

Enling Ma, professor of surgery at Peking Union Medical College, department of international cooperation, said these improvements will require medical doctors to have some administrative skills.

"Since the majority of Chinese hospitals are managed by medical professionals who lack administrative training, your (ACPE's) executive experiences and education programs could be very important to us."

The deligation heard stories of for-profit hospital companies' entry into the health care market, though we did not visit any. At least one of the hospital officials we visited felt that the competition would be good for the government-owned and managed national, local, and regional hospitals.

We also experienced rich cultural activities that will be remembered for a lifetime. From the Beijing Acrobats, Sichuan Opera, the Great Wall, Forbidden City, Tiananmen Square, and Chengdu Panda Zoo in China, to the awesome Potala Palace (traditional home of the Dalai Lamas), Jokhang Temple, Barkhor Square and Sera Monastery in Tibet, our digital cameras came back with thousands of pictures and memories.

For many of us, one of the highlights of the trip was a visit to a small school in the back streets of Old Lhasa--Braille Without Borders, or the Tibet School for the Blind. There, we met Sabriye Tenberken, a 35-year-old German woman who founded the school seven years ago, and her partner, Paul Kronenberg, who works tirelessly to keep the school funded and growing.

Most significantly, as Tenberken and Kronenberg quickly pointed out, we met the most important residents of the school--the children. These 30 elementary and junior high pupils have unlimited opportunities in their lives because of their creativity, determination and enthusiasm for learning. No whining or pity at Braille Without Borders.

It occurred to me that we could learn from the attitude and innovative approach of every person associated with the school. In fact, about two weeks after our visit, Tenberken was featured by Oprah Winfrey as one of a few "Women You Should Know" in the world.

Inner journey

What did we learn about ourselves, and about leadership, in an unfamiliar environment?

First, openness to new views and ideas was essential for a successful trip. Each professional visit was an opportunity to listen and ask questions. Curiosity and the joy of learning were evident every day. As part of openness, we realized fairly quickly that changing the formality of the delegation meetings to allow our hosts to ask us questions was even more interesting. It gave us insight into what was on their minds--not ours. So we did that at each scheduled visit and had very engaging dialogue at each visit.

Second, recognition that each member of the delegation was unique and offered incredible knowledge and wisdom. In fact, at the Peking Union Hospital, one of our hosts had read each CV before our visit and had specific questions for several of the delegates based on his need for information. Imagine how surprised you would be if a Chinese medical leader singled you out by name based on your experience and accomplishments!

Third, we all helped others with difficult situations, whether a fractured foot on the Great Wall, significant respiratory problems in Lhasa or empathizing with those delegates whose homes and businesses were affected by Hurricane Rita. Regardless of the situation, each of us knew we could rely on any of our group to help out in a difficult time.

Perhaps the greatest insight of all is that being part of this experience and adventure helped each of us know that we are capable of adapting to new and challenging situations. The behavioral competencies required of each of us--curiosity, self-awareness, flexibility, respect for fellow delegates and a willingness to find challenging new experiences--are competencies that will serve us well in our careers as we are inevitably exposed to change.

If you are curious about what you can learn about leadership and your adaptability in unfamiliar situations, watch for ACPE's next adventure with People to People Ambassador Programs--a trip to Russia with the next ACPE President, Chal Nunn, MD, MMM, CPE, FACPE, as delegation leader next fall.

Barry Silbaugh MD, MS, FACPE, is the current president of ACPE. He is a senior health care partner with Creative Management Group. He can be reached at [e-mail].

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References:

1. Hutzler C. "China on path to overtake U.S. Economy." Wall Street Journal. January 24, 2005.

2. Browne, A. "Policy Woes: China's Workers See Thin Protection In Insurance Plans." Wall Street Journal. Dec. 30, 2005.

By Barry Silbaugh MD, MS, FACPE

RELATED ARTICLE: Health statistics

Here are the statistics we recorded from comments made by our hosts:

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United States 5.62% GDP (2003)* 14.6% (2002)** $64 per capita* $5,267 per captia (2002)** 2.32 hospital beds/1000 2.9 hospital beds/1000** 1.47 physicians/1000* 2.4 physicians/1000 (2001)** Maternal mortality rate 50.2/1000,000* 7.5/100,000 * Briefing by Ningshan Chan, Department of Health Legislation and Policy, Ministry of Health. Beijing, September 21, 2005. ** Anderson G and others. Health Spending in the United States and the Rest of the Industrialized World. Health Affairs, 24(4): 1903-14, July/ August 2005. </pre> <p>* Health care costs have increased three-fold in the past decade, with continued rapid cost escalation.

* 12.1 percent of the population is covered by insurance; there is no plan for universal insurance.

* About 56 percent of health care expense is paid out of pocket; the government covers 17 percent of health care expense.

* Two distinct delivery systems, each with multiple layers: urban and rural including 18,000 hospitals, 245,000 public clinics, 136,000 private clinics.

* Overall life expectancy: 71.8 years.