Physician executives in China: a diary.

Physician Executives in China: A Diary

Approximately two years ago, the People to People Program approached the American College of Physician Executives to explore its interest in sending a delegation of medical executives to the People's Republic of China. People to People International and the Citizen Ambassador Program were founded by President Dwight D. Eisenhower in the mid-1950s for the purpose of promoting better understanding between the people of the United States and those of other countries. Assembling the delegation during the fall of 1988 proved easy and yielded a delightful mix of personalities, specialties, ages, organizations, and locations. By the first part of 1989, the delegation was eager to fulfill its professional purpose of exchanging information on health care institutions, delivery systems, and health facilities management within the two countries.

The following has been extracted from the delegation's diary, which I maintained throughout the trip to China. I have selected times and events that best typify our experiences.

Beijing, May 30, 1989

Following a briefing session in Seattle; a day lost over the International Date Line; an evening in Narita, Japan; and four hours aboard China Air's Boeing 767, our enthusiastic, if disoriented, delegation (see accompanying box) registered into Beijing's Kunlun Hotel, located several miles from Tien'anmen Square and the Temple of Heavenly Peace. The Kunlun is a bit of a surprise. Its revolving restaurant atop 26 floors, deep-piled carpeting, white-uniformed attendants, and air conditioning are in marked contrast with the discomfort of the day's humidity and with the crowded apartment buildings just visible through the morning mist. To help disoriented travelers, the elevator carpets, which are changed each day, have the day of the week woven into them. Our first full professional day is spent at the Friendship Hospital. Originally called the Sino-Soviet Friendship Hospital, its name was shortened just before President Richard Nixon's arrival to reflect the Chinese government's desire to extend friendship to other nations. We continually found during the trip that medical hosts, conference participants, and hosts from the Chinese Medical Association also signaled that desire for friendship and professional collegiality in our educational and other exchanges. Friendship Hospital is the 700-bed flagship of the Chinese health delivery system. It and its government-salaried physician staff provide a broad array of medical services and were enthusiastic about showing us their facilities--a ward of children with infectious diseases, outpatient clinics, a renal dialysis and transplant program that combines Western and herbal medicines, an intensive care unit with several strip recorders of heart rhythm, an air-conditioned CT Scanner room, and emergency rooms. Our hostess, Dr. Huang is a delightful, smiling women who heads the Beijing Institute for Hospital Management. As she and Dr. Zhen, Director of the hospital, guided us through the darkened and nonair-conditioned hallways of the hospital, the heat and humidity were very noticeable, but so was their pride. In the past 40 years in the People's Republic, life expectancy has increased by 20 years, infant mortality has dropped appreciably, and renal transplant successes have been remarkable. Friendship Hospital is a study of contrasts and transitions. Portions are darkened to save electricity, nursing staffing seems visibly slim, and help from patient's relatives is expected. Patients resting in pipe-framed beds in humid open wards contrast with medical students hovering around the chilly room of CT scanner CRTs. The amenities we in the United States have come to expect from our competitive health care system are absent. Choice of provider is very limited in the People's Republic. Patient care is financed by the state, by employers, and by patients' villages. Care is provided free as long as patients visit their assigned providers. Medical salaries flow from the state, and there is little evidence of entrepreneurism or of private practice in medicine. We were never told what those salaries are, but the physicians noted with some discomfort that the farmer who can sell his excess produce in the city is considered wealthy. The small businessman is becoming the Chinese Yuppie; nurses and doctors are becoming scarce. Papers on medical management were presented to a packed lecture hall at the hospital with the help of courageous interpreters. While the Chinese who attended did not present formal papers, their questions and discussion reflected a surprising knowledge of the U.S. system of health care delivery and financing. "Do HMOs in the United States limit access to care?" "Why aren't doctors running all the hospitals in the United States as they do in China?" "Does hospice mean euthanasia?" Many of the 50 attendees from China had spent a year or more in training in the United States. It is a mark of some distinction and pride to them to have done so.

Many evenings concluded with banquets, which may have as many as 15 courses served by hosts from lazy Susans that seem to be a feature of every round dining table in China. Toasts were offered in order, first by Dr. Wang Shu-qi, Vice President of the Chinese Medical Association, and then by myself, as head of the U.S. delegation. My practiced toast in Midwestern Mandarin required translation into intelligible Chinese by our guide, Madame You. Text books on the subject of medical management were exchanged. Copies of New Leadership in Health Care Management: The Physician Executive will soon dot the libraries in Beijing and Nanjing.

Beijing, June 3, 1989

Following group discussions with members of the Chinese Medical Association and the Society of Hospital Management, visits to the Ming Tombs, and a walk on the Great Wall on previous days, we traveled today by bus to a district hospital in Shunyi Province, which serves 500,000 people in 29 townships. Again, the Chinese, led by Drs. Chen Tong Xiang and Qu Younghui, met us with smiles and laughter. Introductions and tours followed. Dr. Qu, whose English had been tutored by a year of training in Alabama, described the scope of his district hospital: 1,000 outpatients a day, breast cancer the most common form of cancer, no acupuncture, Cesarean section most frequent surgical procedure, infant mortality rivaling parts of the United States. We traveled by Dr. Qu's vintage private car to tour a township health center. Entirely outpatient in service level, the health center focuses on preventive medicine and patient education. A highlight of this tour was a visit to the pharmacy, where occasional bottles by Squibb, Merck, and Pfizer products were vastly outnumbered by the drawers and boxes of herbal medicines. White-gowned assistants proudly opened several of the hundred or so drawers of herbs, filling the warm room with aromas reminiscent of apothecary shops of past decades or the spice markets of Istanbul. Unfortunately, the herbs prescribed to cool down patients didn't work for many of us perspiring guests, and we returned to our bus for airconditioned travel to a village clinic. Tree-lined macadam roads took us to a small village of about 300 people. The local health care worker, previously called a barefoot doctor, and her small but tidy clinic tend to the basic needs of the villagers. Prevention, education, prenatal counseling, and repair of minor injuries are stressed. Bricks of coal stacked in symmetrical pyramids near a iron stove gave silent testimony to the clinic work schedule and about the uncomfortableness of next winter's physical examination for some villager. All villagers contribute a small amount of income to a common fund that helps pay for care in larger hospitals when villagers need it. Tomorrow we leave Beijing for Nanjing, and Tien'anmen Square has not yet been visited. Our guides are reluctant but acquiesce, and we set off on foot. Group excitement and chatter increase as we approach the famous Beijing Hotel, which is located just three blocks down Chang'an Avenue from Tien'anmen Square, the Gates of Heavenly Peace, and the Great Hall of the People. It's the five o'clock rush hour, and nearly all eight lanes of the Avenue are choked with bumper-to-bumper bicycles traveling in all directions as workers of all ages return home from work. There are no troops in sight. White-uniformed policemen are directing traffic. Walking west to the Square, we are struck by the nearly carnival atmosphere. There are vendors selling slices of watermelon and groups of young people reading the latest news posted on billboards or written in chalk on the sidewalk. There are many unaccompanied children, and there is no sense of impending danger. Crossing the Avenue requires using a pedestrian tunnel whose cooler underground walkways are dotted with young people sleeping in bedrolls in the shade and relative quiet of the tunnel. Others are reading posters that paper the walls of the tunnel steps and retaining walls. Our ground level view of the Square was probably less dramatic than that seen on CNN, but the Square's size is impressive. The plaster of Paris replica of the Statue of Liberty prominently faces the street. Her face is at eye level with the huge portrait of Chairman Mao that hangs on the wall of the Great Hall of Heavenly Peace. Perhaps 20,000 people were milling about at the time we arrived. Some were listening intently to the government's message, which was blaring from pole-mounted loud speakers. Others were gathered around students who were using bullhorns to shout their messages. Flags representing various colleges and universities fenced in the Statue of Liberty, at whose feet were two red mountain tents shielding those who were voluntarily starving in protest. We climbed on 55-gallon drums to take pictures. There were other tourists, Chinese citizens with cameras, noise, singing, humidity and heat, tons of litter, no police, no troops, and no sign of trouble.

Beijing, June 4, 1989

Last night as we slept in air-conditioned comfort, the troops of the 27th Army cleared the Square. Our information is now no better than that on the street. CNN, which was previously available in the hotel, has been shut down. We kill time at the Summer Palace, awaiting our planned flight to Nanjing later today. Noises in the distance sound like short bursts of thunder, but there are no visible clouds. At the airport, which is managed and run by the Chinese Air Force, rumors replace air conditioning. Another group of physicians has been waiting for a flight for eight hours, and so will we. We discuss alternatives with our guide, Madame You, but there are none. If there are flights to London or Tokyo, tickets are not sold in the airport. They're sold downtown near the Beijing Hotel, and there is nothing moving there or at the airport. No cars at the airport. No buses. As we shared peanut butter and breadsticks while sitting on window ledges, we waited. Amid frenetic confusion, we are awarded boarding passes on what appears to be the last plane out of Beijing for a time. There is no cheering as the plane wheels leave the bumpy concrete runways, but one could feel the relief. We now head for our planned destination of Nanjing and the scientific sessions with the Division of Hospital Management of Jiangsu Province. Our visit to China at this point is not yet half over, but already much has filled our diaries and camera. During the next weeks, we will continue to deliver talks at hospitals and clinics, visit local sites, be delayed, temporarily surrender our passports, worry about revolution, celebrate good fortune, phone home a lot, tire of the Lazy Susans, and indulge ourselves in Hong Kong. The students and the protesters will close the bridge over the Yangtse River, listen to the BBC for news, and stage mock funerals for Lady Liberty. We'll learn later that Miss Liberty is truly ill.

Robert B. Klint, MD, MHA, FACPE, is President and CEO of SwedishAmerican Hospital and Corp., Rockford, III.