The Chinese Doctor

Fascinated by the Chinese culture, I had researched what it was like to be a doctor in China. My thinking was that if my Chinese was good enough, I could go to China to practice for a few months to a year or so, and develop more of my Chinese, as well as see how healthcare works in another country. I didn’t mind if my wages would be much lower, but it was the experience that would make the decreased wages worth it.

My research led me to see how fractured and weak the healthcare system in China was.

Doctors are overworked, and underpaid. A lot of doctors provided substandard health care as a result of an overwhelming number of patient demand that could not be met by the health care system. With a country that has over a billion people, it’s no wonder. Coupled with the fact that there has been a net migration of rural residents flooding into the cities, and this will burden the health care system a lot.

Last year, my grandma needed to pay a visit to the hospital as a result of what was likely an asthma attack. In the hospital, everything is based around the almighty dollar. A deposit of around 5000 yuan was required upon being admitted as a patient, just so that you will be able to pay for your medical fees. And what should happen if you end up spending all that 5000 yuan? You get refused medical service. My aunty managed to bargain with the doctor’s in hospital and was able to bargain the deposit down to 2000 yuan. But a couple of days as a patient, my grandma was not given her morning medications. When asked why, the nurse advised that her 2000 yuan deposit was all spent, and no medications would be provided until this amount was topped up.

Other things that seem to be wrong with the health system there, is the encouragement of the “hong bao” or red envelope. In China, a red envelope contains money, and is often given as a token of goodwill. For the rich in China, giving a red envelope gives them a sense that things can be accomplished more quickly, that the doctor will spend more quality time with the patient. My mum who had been to one of the hospitals had clearly seen a Chinese sign that states “No red envelopes allowed”, yet I’ve heard that this gets curtailed by the use of credit cards given instead that are loaded with money.

The way that the doctor gets paid is also shocking. Doctors seem to get paid for prescribing things. In that way, this ends up to a lot of unnecessary prescribing for the sake of earning extra money. My father who had gone to one of the hospitals because of an upset tummy and 1 or 2 episodes of diarrhoea was offered IV fluids. He wasn’t dehydrated or anything, and didn’t need the IV fluids. Why give someone something when the risks of infection from the cannula etc outweighed the benefits? Perhaps by giving IV fluids, it is relatively “safe” and makes good money as well, and in the minds of other patients, they think something is being done.

Finally, perhaps the most disheartening thing I’ve read, have been doctor killings from patients. A times article sums up this perfectly here.

It’s quite sad actually, but I’ve been told that being a doctor in China is not what people aspire to, given the great responsibility and little financial reward given. I don’t blame them given the way doctors are being treated there.

 

 

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Drug Seekers

“Oh, but I just ran out of my oxycontin medications the day before coming into hospital. Could you write me a script for when I go? I won’t see my GP until 4 days time”.

Sigh. This man was on 90mg of oxycontin a day for back injury sustained years ago. The pharmacist thought his story was dodgy, as did the nursing staff. Bells and whistles were going off, and I couldn’t help but think that this is one of drug seekers that I’ll be facing for the rest of my career.

The nurses had found syringes in his belongings. Not only that, but his story was extremely sketchy. There was an unaccounted period of 3 months of which he hadn’t obtained any oxycontin from his last GP. He must have been doctor shopping in that period of 3 months. In addition to all this, the man was demanding. He told the nursing staff that he wouldn’t leave hospital until he got some scripts.

I didn’t know what to do. I had a feeling that I could perhaps tell him that it is not one of my policies to discharge people home on strong pain relief when I am not familiar with their medical history especially in regards to his pain and his scripts. Being like any junior doctor who is stuck about what to do, I phoned my registrar. She told me to just give the scripts. So, I wrote the scripts (only for 8 tablets however – to last him till his supposed appointment with his GP in 4 days time) The man took off shortly after being given the scripts. I felt defeated.

Reflecting in hindsight, I don’t really see why I didn’t just decide to not write the scripts in the first place. There were 3 months of unaccounted scripts of oxycontin that he wasn’t getting from his regular GP, his story of running out of medications was extremely suspicious, and the nurses found syringes in his belongings. My biggest fear at the time however, was always the thought that what if I don’t write the scripts and he definitely had no medications? I thought about not writing the scripts and telling him to see ED if there were any issues with pain, but it felt irresponsible. Also, I was afraid of what would happen with his threats of not leaving until he got a script. These patients sure are scary (he looked scary too – missing a few teeth, menacing eyes that glared at you).

I recently read an article (http://www.racgp.org.au/afp/2010/august/prescription-drug-misuse/) that deals with the very issue of drug seekers. They’re a challenging group of patients to cater for. They may use tactics of intimidation, and guilt tripping to get what they want; more pain medications. In Australia, oxycontin and alprazolam are the most abused drugs. What’s more, there are an estimated 20,000 prescription drug shoppers in any 3 month period.

The article goes on highlighting some strategies to deal with the drug seeker, something like saying “it’s my choice” or saying “it’s our policy that we don’t prescribe strong opiods/benzodiazepines for new patients” effectively giving no room for negotiation from the patient. The second strategy is really good, but I feel the first one could still give room for a drug seeker to negotiate and manipulate. One thing the article really highlights however, is the fact that role plays with such scenarios have shown that doctors are initially embarrassed or too shy to say no to drug seekers.

Would I write another script for a suspected drug seeker? Probably. But I’ve learnt something from this encounter. I learned that it’s quite hard saying no to a drug seeker. But with this experience in mind, I’m in a better standing for that next encounter with the drug seeker.

Panic in the Restaurant

I’ve heard it said before, that chefs don’t like to come home to cook dinner. I see the truth in some of that, as the last thing that I’d really feel like doing on returning home from work, is to focus on more medical things.

But sometimes, there is no other choice, and you just have to. Medical problems that my parents or grandma wants advice about are directed towards me when I come home. When things like “I’ve been getting cramps these last 2 days, what is the reason?” are asked, it’s an incredibly difficult position to comment about. So I try and take a history to glean more information, essentially to determine if it is something serious in nature, or something relatively minor that doesn’t require urgent treatment.

When it comes to things such as these, I don’t want to end up completely treating my family members. I’m happy to provide some advice, but when it comes to some medical problems, I don’t have access to diagnostic tests to confirm suspicions, and that’s why I think that if the issue really warrants serious investigations and treatment, it is best managed by their regular GP. I realized that a doctor without any medical equipment, diagnostic tests or medications is the equivalent of a medical student – just full of knowledge and differential diagnoses, but essentially unable to do anything much else.

This concept of being unable to do anything much was best demonstrated just a couple of days ago. My grandma had only been discharged from hospital for less than a day, but she was extremely keen for some lunch at a restaurant. So out we went to eat some greasy unhealthy Hong Kong food (which gave my Dad and I diarrhoea later that night by the way). Part way through lunch, my grandma turned a sickening pale, then blue colour in the face. She became limp, head starting to slouch. Her consciousness seemed to slip away as seconds passed by. I thought she was having a stroke. Fear seized me momentarily, with pure negative thoughts of gradual decline to a terrible quality of life, and what may be a painful slow death after what followed.

“She’s not responding” my father fearfully exclaimed in cantonese. I must have snapped out of my fearful state following that, and pounced into “doctor mode” after out. Bolting to my grandma’s side, I immediately thought of ABCD, checking for responses (COWS – Can you hear me, Open your eyes, What’s your name, Squeeze my fingers). By now, I mentally thought of hitting the MET call button, which translated to calling the ambulance. Enlisting help from the restaurant staff, I calmly told them that my grandma was in trouble and I was calling the ambulance. The manager took over my phone, continuing the call as I couldn’t give the exact address.

Throughout all this, I didn’t feel like I did a good job. I didn’t know aside from thinking about differentials and continuously assessing her conscious state, what else I could have done in that situation. I felt completely powerless removed from the hospital environment. One of the nearby nurses from a GP practice was called over, and helped to take a BSL and blood pressure.

As my grandma become more alert gradually, her only concern was that I attend my job interview with one of the hospitals that I was applying for next year. She urged me numerous times to attend. After what seemed to be about 5 minutes, she was more alert in herself, and the paramedics had arrived. My mum would accompany her to the hospital, and from my grandma’s urging, I ended up attending the job interview.

Perhaps what added to a particularly anxiety provoking day, was when the interviewer gave me a clinical scenario about a MET call patient. What a coincidence – I’ve just been through one already.

Suffice to say, I probably wasn’t performing at my peak after what happened. The interviewer felt I was too nervous, and felt I couldn’t control my nerves (I found it odd for some reason for an interviewer to specifically mention that). I thought the better of mentioning what happened to my grandma – I don’t want to be seen as someone who wants sympathy points.

I went home by bus, and went straight to the hospital afterwards. My grandma had perked up much more, and looked much better. But what a day that was. What a day!

Back to the Surgical Wards

I’m back on that horrible horrible surgical ward, the ward of bad memories from last year. The constant buzzing in the ward of bells and alarms is all too obvious. I see some familiar haunting faces. Faces that give me a nauseating feeling of disgust.

It’s a good thing that those haunting faces are on the other side of the surgical ward. I’m looking directly back at those past surgical consultants that gave me such a hard time last year, from the desk of the orthopaedics team.

For the mean time, I’ll be looking after bones, joints and wounds, as opposed to botched up colon resections, dehisced surgical wounds, and bladder to abdomen fistula-from-bad-surgery (all of which I really did encounter during my surgical time last year) thank you very much.

Our orthopaedics patients are few in number (sometimes only 5-6 on the ward), generally quite well post op (joint replacements – what can go wrong?), and have far fewer comorbidities. Our team is fairly large too (3 residents vs 4 for surgery, but much fewer patients, and way less clinics).

Some of my registrars still suck, with one even being a registrar from last year. He assigns some of the most time wasting tasks for me, at one time, phoning me up and slowly dictating all the patient details to me so that I could write up a theatre booking form. It was painstakingly slow, dictating the patient’s name, and at times, missing a few letters so that I’d ask him to repeat again. Makes me question the registrar’s judgement in that firstly, it would be much quicker for him to fill the damn form out himself, and secondly, he’s not only wasting his time, but also the resident’s time, therefore wasting two people’s time.

Some things in orthopaedics remain the same as surgery however. The mad frantic rush in the morning ward rounds as we jump from patient to patient, and the unclear plans for VTE prophylaxis, as each consultant likes different VTE prophylaxis use. On the other hand, a lot has changed too. There are way fewer MET calls on our side, or constant requests to review unwell patients, and way less phone calls from other staff hurrying us to get certain jobs done.

Yeap, I enjoy orthopaedics way more than surgery. I’m just thinking how much it sucks for the surgical residents now, but I can empathise with them at least. Been there, done that.