Michelle Renshaw is the author of Accommodating the Chinese: The American Hospital in China, 1880-1920, a history of American medical missionary involvement with China, from the latter half of the 19th century through to the late Republican period of the early 20th century. The book, as we have mentioned before, is a must read for those wishing to understand China’s current medical system, and even more so for those interested in Chinese hospital.
Today we present part one of a two part extensive and fascinating interview with Michelle (Part II is here). The whole of the interview was conducted by email after an initial phone conversation. On account of the fact that Michelle has recently returned from a trip to Suzhou, Jiangsu, where she toured several hospitals, including one that she profiled in her book, she was able to give us a fresh take on what she saw and she relays it to us here.
Part one will focus on her impressions of what the Chinese hospital looks like today, how it differs from a typical American hospital, and the important cultural considerations that would-be hospital builders and investors need to make when thinking about how to design or upgrade a hospital, in China, intended to cater to Chinese patients. If you take one thing away from this interview (though, really, the insights in this interview are many) it is that success in China’s hospital market will require a strong effort to adapt to local customs and expectations.
What are you working on now? Where are you working?
I hold an unpaid position as a Visiting Research Fellow at Adelaide University in the Faculty of Health Sciences (Public Health) and operate as an “Independent Scholar”.My current project involves exploring how the contemporary cultural, political, legal and medical environment influenced the extraordinary surgical success of early medical missionaries in China. I argue that a patient being operated on in China in an adapted warehouse building by a sole practitioner, with no running water and no nurses was more likely to survive than their counterpart in America. The question is – why?
More recently I have been looking into how the hospital’s place in the overall health system, in China has evolved since the 1920s.
Private hospitals do not enjoy a good reputation in today’s China. There is a generalizable sentiment that private hospitals over-treat without regard to a patient’s ability to pay, and that the care in private hospitals is inferior to that received in public hospitals. In Accommodating the Chinese you write about how medical missionaries worked to overcome the distrust of the local population, and for some medical missionaries this meant accommodating to local notions of décor, payment practices, and even moral values.
If the perception is that private hospitals overcharge and give inferior care then cosmetic changes will not alter that view. A patient, to a medical missionary, was neither ‘clinical material’ nor a source of profit but a body to be healed and a soul to be saved. That attitude, seems to me, is what drove their adaptations.
Given that the modern Chinese hospital structurally looks a lot like the modern American hospital, and that modern Chinese physicians train with the same materials that modern American physicians do, are there aspects of Chinese hospitals today that are uniquely Chinese?
Though they might look the same I see the American and Chinese hospitals as almost distinct species. This is why:
The medicine that medical missionaries introduced to China was, essentially, “hospital medicine” and the large bulk of modern medicine delivered in China today is still “hospital-based”. Of every dollar spent on health care in China 76 cents are spent on or in a hospital. This is starkly different from the situation in, say, the USA or Australia where a comprehensive private GP and specialist systems feeds the predominantly inpatient hospital system. Just as they did in missionary hospital dispensaries, today’s Chinese patient still interacts with the public general hospital directly via an out-patient specialist clinic not the inpatient department. Only about 3% of all patients treated in missionary hospitals were admitted as inpatients. Today that ratio is not significantly different (according to data from PUMC Hospital and First Affiliated Hospital of Soochow University). This pattern of usage is reflected not only in the size and physical layout of a hospital but also in the patient’s view of the hospital and their relationship with it.
Chinese patients have demonstrated that they are comfortable with, and prefer, going to large hospitals, the bigger the better. So long as patients can consult a specialist directly, rather than having to be referred, they will do so. Whenever stand-alone health clinics have been established with the idea they would act as hospital gatekeepers, patients have bypassed the gate and gone to the highest level of facility they can access, either physically or financially.
Can American hospital builders going into China today build a successful hospital without making any significant efforts to change the nature of their hospital model?
Short answer – no.
I imagine that it is highly unlikely any private operator could match the quality, range and depth of services offered in a modern Chinese research and teaching hospital. Even without the research and teaching aspect the cost of the sheer number and quality of specialist services required by ambulatory patients would be prohibitive. Specialist hospitals, of course, may be a different story.
Chinese patients are autonomous, savvy consumers of health. Even today, it is they who decide which specialty, and often-times which particular specialist, to consult. In other words, they act as their own diagnostician and they make judgments about medical competence. They also ‘manage’ their own care to a greater extent than we are used to in the west. American providers would need to adapt the way they interact with patients to accommodate sophisticated consumers.
A couple of, what might seem to be insignificant, considerations come to mind:
(a) How to accommodate the view of the doctor-patient relationship and the role of the family in Chinese hospitals? Traditionally in China, when a poor prognosis needs to be relayed, a patient’s family is informed and they decide what and how much to tell the patient. Similarly, the accepted western practice of gaining a “competent” patient’s consent to medical treatment might not be simply transferable in a country where the law allows for a patient and/or a family to consent. (I have written about the role of families in mission hospitals in “Family Centered Care in American Hospitals in late-Qing China” in Graham Mooney and Jonathan Reinarz (eds), Permeable Walls: Historical Perspectives on Hospital and Asylum Visiting (New York, Rodopi, 2009) pp 55-79.)
(b) How to deal with patient medical records? Chinese patients have always owned and been responsible for maintaining their own health records. Entries are made by the practitioner during the consultation and by the patient between visits. The resulting comprehensive record serves as a reference point for new and ongoing discussions between doctor and patient and, vicariously, with all previous and current medical practitioners. It is clear from the Chinese people I have spoken to that they value their medical records and would be loath to forgo the responsibility of keeping them. I imagine this practice would raise issues of ownership for private foreign operators.
You recently went to China and toured some of the hospitals there, a few of which you wrote about in your book. What reactions did you have during/after these visits?
I was delighted to find the hospital in Suzhou, Jiangsu, first established in the 1880s morphed into the First Affiliated Hospital of the Soochow University on the same site. Exploring the thoroughly modern, 54 acre, campus and wandering through the outpatients department I was struck by a feeling of calm professionalism of staff and the confidence of patients.
There was an abundance of information in the form of signage and people on hand, including a help desk, to enable patients to navigate the system. Interesting to me, and I don’t know why, but in every hospital or clinic all signage was in English as well as Chinese.
Given the importance Chinese patients have always placed on a doctor’s reputation, the prominently displayed lists of staff, often with photographs, make it easy for a patient to choose with whom to register.
The problems of long lines of patients waiting to be registered appeared to have been solved by locating separate registration offices for the various specialty departments on the appropriate floor.
I was impressed by the extent of computerization which not only presumably improves efficiency but also makes the patient’s life easier in a facility that caters for 1.3 million visits per year. Each patient has a ‘patient card’ to use in ATM-like machines to make appointments as well as to access their records, test results etc. They can also make an appointment online or by phone and the hospital’s website provides a wealth of information, including a timetable of all specialist clinics with the name and position of the staff member in attendance. Patients can even use the online “ask a physician” service.
The capital investment in every hospital I visited was obvious; all had extensive new building work in progress. The lobbies of the newest buildings, which could have been mistaken for those of a modern hotel, are designed to be as welcoming as those the missionaries built. It was my impression that the public had greater access to a wider range of zones in the hospital than I am used to in Australia. I wrote in my book about how medical missionaries protected themselves against charges of mal-practice by enabling ‘transparency’ in their interactions with patients by their buildings layout. Some western commentators assume that Chinese patients want more privacy – I think that idea should be tested.
…Tomorrow we’ll continue with Part II.
To contact Michelle, please go here.