Misadventures at a Chinese Hospital in Qingdao

Our About page says we’re “trying to live into and love — and some days just survive — China.” That last bit is just supposed to be some tongue-in-cheek hyperbole, but it recently became a little too literal.

For reasons that no doubt expose my questionable judgment, I tried to use the nearby local Chinese hospital in our un-redeveloped patch of an older outlying district of a wannabe 2nd-tier Chinese city, rather than the big downtown hospital that sometimes has Western-trained doctors in a clinic specially targeted to foreigners. I mean, how complicated could it be to get treatment for a persistent cough? What could go wrong, you know? As it turns out… a few things.

* * * * *

Why Not Choose a Local Chinese Hospital?
Of course we’ve seen the headlines and heard the stories about Chinese hospital corruption and low standards. But we’ve had two tolerable experiences at this particular hospital before: once when our two-year-old had bad pneumonia she got prescribed oral antibiotics and breathing machine meds (when we resisted hospitalization), and recently when the same kid had diarrhea she got prescribed ‘normal’ diarrhea medicine plus Chinese herbal belly button plugs (just for kicks).

I figured it’d be more convenient (wrong) and less expensive (also wrong) to visit a Chinese doctor I could walk to and pay 6元 to see rather than visit a maybe-Western-trained sort-of English-speaking Chinese doctor who costs 100元 to see plus 70元 in taxi money round-trip. And just the fact that I knew I could navigate a Chinese hospital visit on my own kind of made me want to give it a shot.

* * * * *

How to Get From the Front Doors to a Filled Prescription… in 11 Easy Steps (at least)
The Number “4” People’s Hospital is pretty average; you can find better and you can find worse (it wasn’t actually the Number “4”; I’m obscuring that detail to protect the possibly-guilty and because “4” means “die” in Chinese).

The process…

  1. from walking in the door and taking a number (<5min)
  2. to paying, getting a card, and registering to see a doctor (15min)
  3. to seeing a doctor (15min)
  4. to paying for tests (15min)
  5. to getting tests done (45min)
  6. to picking up the test results (30min for blood; 4hrs for CT printout — but the doctor has them almost instantly via the hospital’s computer network)
  7. to seeing the doctor again for a diagnosis and prescription (15min if you spend time arguing like me)
  8. to getting the skin test done to check for allergies to the prescribed meds (20min)
  9. to paying for those meds (15min)
  10. to receiving your meds (5min)
  11. to getting your IV drip prepared and inserted into your circulatory system (IV drips are a national pastime in China) (15min)

…can appear daunting at first. Each one of the points above represents a trip to a different window and/or office and/or machine, and most of them involve standing in crowded noisy lines of other sick people. (The times above are what it took for me the other day.)

Honestly, Number “4” People’s was decently navigable; at any point in the process you can ask a nurse at the booth by the main entrance and she’ll tell you what to do. To get your test results you insert your hospital card into an ATM-like machine (your name displays on a screen when they’re ready to print), but the doctor had my results on her computer before I’d made it back to her office from the testing room.

But you should probably bring a Chinese friend if:

  • You’re too sick to stand for a while in the crowded heat and yell through glass windows and run around a bit;
  • You don’t have at bare-minimum solid HSK4-level Chinese (this might not be enough). Aside from the all the medical vocabulary, it’s just noisy and hard to hear clearly.

* * * * *

How Not to Handle Your Average Local Chinese Doctor
I’d walked in at 9:30am and ping-ponged through Steps 1-6 by 11:10. Now I’m back in the doctor’s office (Step 7)… and this is when things start to go bad.

I’m not saying ‘bad’ because there’s no privacy with the door wide open and other people in the room, one of whom will eventually chime in on my consultation — that’s normal and expected. I’m saying ‘bad’ because she looks at my CT scan and says: “You need to be admitted for 7-10 days and take IV antibiotics.”

“Can’t I just take antibiotics pills? I’ve never needed an IV before. Usually we just take pills for this.”

“You’re pneumonia is too serious for pills. You need to be admitted. Look here…” She shows me her screen:
CT_scan_pneumonia
“…That’s your heart. That black part is your lungs. It’s supposed to be all black. See all this? This here that looks like meat? That’s the pneumonia.”

This is not what I want to hear. As if I know how to judge the seriousness of a CT scan. And sure, I know the Chinese doctor stereotypes — over-treat everything (especially with IVs and unnecessary hospitalization and surgery) just to make extra sure, and never mind a financial incentive to over-prescribe — but I mean, come on. Really?

There’s no way I’m being admitted; we leave for North America in just over two weeks, we have a newborn and two young kids at home, and I have work to do. So I’m still aiming for pills while trying not to be too rude: “I can’t be admitted; that’s impossible. Can we really not use pills in this situation?”

“I really don’t want to give you oral antibiotics,” she says while flipping through my CT images, “Not for pneumonia that’s this serious.”

I haven’t given up yet, “Well, what’s the difference between me taking pills or an IV? Is it just that pills will take longer? Because I don’t mind! I can take pills for weeks if I need to!”

“Your pneumonia is really too serious. You’ve got to be on an IV…” She will not budge. After some more back and forth — during which I wish now that I’d just flat-out refused and forced her to give me pills — I agree to come sit in the hospital’s Infusion Hall twice a day for four hours at a time for three days, after which she’ll maybe consider giving me pills depending on my progress. We also go back and forth about whether I can just do the IVs in our neighbourhood’s clinic, but she refuses. I have to come into their hospital twice a day for four hours at a time.

It’s insane; I can’t believe I’m agreeing to it but my only other option is hospitalization, and by this point I’m feeling pretty sick.

infusion_convoI want to walk out and catch a cab straight to the foreigner clinic at Qingdao Municipal or even to super-expensive Family United — anywhere a doctor will prescribe oral antibiotics. But here’s the catch: it’s the beginning of the Dragon Boat Festival national long weekend. Jessica’s already called both those other hospitals and neither has an American-trained doctor available. At Family United I’d have to go to Emergency, so with tests we’re talking 10,000元 (their nurse’s estimate!) and I’d still be seeing a locally trained Chinese doctor!

* * * * *

From the Infusion Hall to the ER… in under 10min
So that’s why I show up again at 3:30 to collect my CT printout and go on a drip for the first time in my life (though we did sell plenty of our plasma in college; I’ve got lots of experience sitting in a chair for hours with a needle in my arm).

It takes more time to get from Step 8 to Step 11 than I’d anticipated (plus I wasted about 15min standing in line at the wrong time). I send Jessica this photo at 4:28. The drip’s been in for about a minute:
POd_inthe_infusionhall
I’ve got my laptop so I can do some work, and my Chinese reading’s loaded on my phone. Neither has enough battery to last the full four hours, even used consecutively. I’ve forgotten my book. So far I’ve been polite to everyone and kept my face pleasant, but I’m in a foul mood. I can’t believe I’m going along with this. I’m about to start in on my Chinese reading when…

…huh. does my stomach feel weird? i don’t think so… maybe i’m imagining it? or does it? it’s hard to tell… … wait, no, it does feel a little weird, maybe i’m hungry… … wait, are my fingers tingling? the heck…? my fingers are tingling… … oh man i need to rest my head somewhere…

“Hey, nurse! Please come here.”

“What?”

“I feel uncomfortable.”

“Oh! Haha. I don’t know. Hold on… Hey! Older Sister! Come here!” I see her wave down a nurse who looks slightly older than this rookie, who’s in the middle of a funny conversation with a coworker. They all get off work in about 20 minutes.

…am i sweating? i’m sweating… why am i sweating…

“What’s the problem?”

“I feel really uncomfortable,” I’m slumped forward in the chair, I wonder if I’m slurring.

“Here eat this.” She shoves a piece of candy in my mouth. I crunch it down as fast as I can. One of them pushes me back up into a sitting position.

…candy? the heck… oh man this is not getting better… i’m sweating buckets… i must be dripping on the floor… i’m dripping… ohhh black stars… white stars… am i gonna barf? …if i barf where should i barf? …not on my clothes… clear a space on the floor here…

Suddenly there are doctors — two, I think. They’re talking to the nurses. One looks straight at me and says, “What’s your name?”

“My name is Lu Tianlang.” …fuzzy black stars on the edges of my vision… and blinding bright whiteness like the washed-out parts of a photo…

His face is right in front of me, “Have you eaten? Did you have lunch?”

“At three in the afternoon I had three zongzi.”

He turns to the others, “It’s definitely not low blood sugar.”

…slumped… sweat… tingling… i can’t see clearly… a face, question…

“What is your name?” All I can see is his face and collar; all around and behind him are the bright white shining stars. I try to focus on his face.

“My name is Lu Tianlang.” …pretty sure i slurred that one…

An old man wheels a gurney up, they help me climb on — I’m oddly aware of the fact that I remember to grab my phone first — someone puts the laptop between my shins, they’re wheeling me down the hall. I think I hear them say the word in reference to whatever IV solution they used to swap out my medicine (guessing it’s this). I can feel the stars and tingling start to recede, and I tell them I’m starting to feel better. The doctors seem happy; they try out some English on me.

Chinese_ER_convoIn the neighbouring building’s ER they take blood pressure and do an EKG. I watch the doctor read the printout. He smiles, gives me a thumbs up, says I’m fine and leaves. I flag down a nurse who says I can go as soon as my drip bag is done in about 45 minutes. I’d better think of something to tell Jessica…

* * * * *

Outside the main entrance I thankfully get a cab immediately. The driver’s 60 years old. We chat. I mention what’s just happened. He takes a sideways look back in the direction of Number “4” People’s and mutters, “That place is no good. They don’t know what they’re doing in there. I don’t go there. They don’t know what they’re doing…” Then he lectures me about the importance of being healthy.

I’m feeling crappy and slightly scared. I have no medicine and tomorrow I’ll have to try another hospital. But I’ve got all kinds of warm feelings for this taxi shifu. It’s like ‘China’ decided to throw me a bone after all, even on a Bad China Day.

* * * * *

Salvation
1:30pm the next day is the soonest I can get to see a foreign-trained doctor — a “Dr. Qi” who works at the Municipal Hospital’s International Clinic. I imagine the consultation being mostly in Chinese, like the previous two times I’d seen doctors at that clinic.

But then he walks in and starts speaking *American.*

What?! …JACKPOT!!! MY NIGHTMARE IS OVER AND I’M GETTING PILLS!!! I COULD KISS THIS GUY RIGHT NOW! (Except for, you know, the pneumonia.) I wonder if the shock showed on my face.

I suspect he gets this reaction a lot. Another China long-termer in Qingdao told me later,

“I cried the first time I went in to see Dr. Chee. I couldn’t believe I was doing it in English and I just lost it right there in his office!”

I can understand that!

Turns out his name’s not even Qi (Mainland Chinese spelling for the surname ) like I’d assumed from hearing it spoken; it’s Chee (for ), as in his family probably originally immigrated from Hong Kong or somewhere (mine originally came from the Ukraine and Switzerland — hey, small world!).

This doctor visit is a full-on miracle of modern medical science. He’s better than a lot of doctors I’ve seen in North America, and I’m not just saying that because he prescribed me oral antibiotics that are literally 5x cheaper than the IV meds I’d bought the day before. If you are a sick English-speaking foreigner in Qingdao, Dr. Chee at the Qingdao Municipal Hospital’s International Clinic is your man!

* * * * *

One Final Awkward
But there’s one last task to do on the way home: get that nearly 600元 worth of IV antibiotics refunded. This requires authorization from the doctor who prescribed them. So I’m going to walk into her office at Number “4” People’s with some other hospital’s blood test gauze taped to my arm and a bag of pills that she wouldn’t give me but some other doctor obviously has, and ask her to refund two huge bags of stuff she insisted I buy even though I’d said I didn’t want to, and even though submitting to her treatment had landed me in the ER. Awkward.

I walk straight up to her office just after 4pm without taking a number (she gets off at 5). I’m polite and smiley; she’s chatty, if a bit flustered and rushed. She’s assumed I’m there to return the drugs and immediately gets after it. I can’t describe the process because she personally does all the running around between floors and departments and windows for me — I just follow her and stand off to the side.

We talk all about what happened 24 hours before, and she keeps saying, “It’s really strange!” over and over. She doesn’t verbally apologize, and we don’t even come close to broaching the subject of, “So what do I do now?” Apparently it’s an unspoken understanding that I’ve found another doctor, or at least that I won’t continue with her. She’s super accommodating, and at 4:30 hands me my partial refund, says a hurried goodbye and rushes into the elevator with someone.

Was it an unspoken apology? Was she afraid I’d make trouble? Collusion between the pharmaceutical and medical industries is rampant in China, and her prescription cost 5x more than what the American doctor at a more prestigious downtown hospital prescribed. Was she afraid of being accused of something? I can’t know, but it’s all possible.

And no joke: they refunded me 444.64元 (of 581): “Die, die, die, unimpededly die.” That’s gotta be the most inauspicious Chinese hospital receipt ever.

* * * * *

That evening I thanked her on Weixin for helping me return the drugs; I just wanted to say goodbye and close things out. She replied with a written apology and a 100元 hongbao:
doctor_apology_hongbao

Not at all, I still feel apologetic. It was Bangda [a particular drug], and you did a skin test, so I thought it over, not excluding being too nervous or low blood sugar. But no, how about you first take oral antibiotics and see. I’m really embarrassed, I hope you’ll understand! Here’s a hongbao to express my apology!

I asked several different Chinese friends how to respond to that: Should I take the hongbao? Not take the hongbao? What should I say? I replied with what one of them told me to say, and tried to return a portion of the hongbao like another suggested (she didn’t take it):

It didn’t cause a health problem, so it’s fine, medical science isn’t perfect, anyone can make mistakes, let’s just consider it my contribution to the accumulating experience of medical science.

How often does that happen in China? A doctor giving a patient a hongbao? It’s usually the other way around. Here’s the anti-bribery sign from the front desk at the international clinic in the downtown hospital:

no_hongbao_please
HONEST MEDICAL TREATMENT, REFUSE TO ACCEPT HONGBAO
诚信医疗 拒收红包
Now that I think of it, I didn’t see any of these signs at Number “4” People’s. Maybe that should have been a clue! (Here’s another one from a previous medical adventure in Huangdao.)

Diagnosing & Prescribing for Pneumonia
Qingdao Number “4” People’s Hospital:

  • Consult: 6元
  • Meds + IV fees: 597元 (and pressure to accept hospitalization!)

Qingdao Municipal Hospital’s International Clinic:

  • Consult: 100元
  • Meds: 118元

I want to assume the best and give benefit of doubt, but a part of me still wonders how to interpret that 100元 hongbao apology.

Anti-bribery signage at our hospital in Huangdao, China

Health is one of the biggest worldview disconnects between Chinese and Western cultures. Another is ethics. Putting it simplistically: To us, their stark pragmatism sounds amoral and selfish. To them, our abstract principles sound naive and heartless. It’s mutually appalling, and mutual understanding is nigh impossible. (Parenting has gotta be in the top 5.)

We’re halfway through a week in the hospital, and I thought this anti-“hongbao” signage was interesting. “Hongbao” (红包) is an ingrained aspect of Chinese culture where the patient’s family slips extra money to the surgeon in a “red envelope” to encourage better treatment. It’s illegal in Chinese countries, but that doesn’t stop it.

Front and center on the nurses’ station:


Honest medical treatment; Refuse to accept hongbao
诚信医疗拒收红包

Despite this, the translator assigned to us (she’s helpful, but her English is harder for us to understand than the doctor’s Chinese) says, “Sometimes, it still happens.”

Apparently there are a lot more ways than hongbao for doctors to earn extra ethically-suspect income. This poster is at the entrance to our floor:

To Strengthen Medical Treatment Clean Behaviour Customs, Construct “The Nine Forbiddens”
加强医疗卫生行风建设“九不准”

  1. It’s forbidden for health care personnel personal income to be connected to medication or medical examination income.
    不准将医疗卫生人员个人收入与药品和医学检查收入挂钩
  2. It’s forbidden to take a commission.
    不准开单提成
  3. It’s forbidden to receive payment against the rules.
    不准违规收费
  4. It’s forbidden to illegally accept social welfare subsidies.
    不准违规接受社会捐赠资助
  5. It’s forbidden to participate in marketing activities or distribute medical advertising against the rules.
    不准参与推销活动和违规发布医疗广告
  6. It’s forbidden to fill prescriptions for business purposes.
    不准为商业目的统方
  7. It’s forbidden to use illegally and selfishly procured medical products.
    不准违规自私采购使用医药产品
  8. It’s forbidden to accept kickbacks.
    不准收受回扣
  9. It’s forbidden to accept patient “hongbao”.
    不准收受患者“红包”

I don’t think hongbao is good despite what the authors linked below argue. But simplistically dismissing it as a bribe without first understanding it isn’t that helpful either. Looking more closely at the reasons and dynamics of this old practice also provides a helpful window into Chinese culture and common ethics. Here’s a bit from an American hongbao apologist:
From China, With Pragmatism

It is very common for a Chinese family to give hongbao to a surgeon who is about to perform a procedure on a family member. Everyone knows to do this, and everyone does it to the extent that they are able. The Americans in our group thought this practice was unethical bribery, because it sought to bias the doctor in one’s favor. The Chinese people at the table replied, “Of course it biases the doctor. That’s why we do it.” Not only were they mystified by the censure, but the Chinese were prompted to ask if the Americans had any children — for every parent surely uses any means necessary to protect loved ones.

When one embassy officer (working his best “hearts-and-minds diplomacy”) suggested that the Chinese switch the giving of hongbao to after the successful operation, rather than before, the Chinese were struck dumb with astonishment. Of course, you have to give the hongbao beforehand because it motivates the doctor. The gift tells the doctor: (a) to take special care with our child (b) we respect your surgical skills/education and “give face” accordingly (c) we are devoted to our child, will hold you responsible and have the means to do so. The fact that not everyone can afford to influence their doctor with hongbao is not grounds for withholding it, since we’re trying to protect my child here and now. The parent, according to the Chinese, should never weigh the child’s well-being against something so arcane as an abstract principle.

And here’s another piece that spreads the blame around:
Bribery serves as life-support for Chinese hospitals

Bribery is the lubricant that helps keep China’s public hospitals running, and the health system would struggle to function without illegal payments to poorly paid doctors and administrators, say medical practitioners and industry experts.
[…]
A doctor fresh out of medical school in Beijing earns about 3,000 yuan ($490) a month including bonuses — roughly the same as a taxi driver. A doctor with 10 years experience makes around 10,000 yuan a month, according to Peter Chen, chief executive of privately run Oasis International Hospital in Beijing.

“Without the grey income, doctors would not have the incentive to practice,” said Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations in New York.

Dealing with the problem is not so easy:
Should Doctors Be Rewarded for Refusing Bribes?

hongbao is adding to the financial pressure most patients are already under, at a time when medical and health cost is very high. The public has long expressed their dissatisfaction with this accepted practice. The government has already taken a number of measures to save the deteriorating patient-doctor relationship resulting from hongbao by announcing that doctors who take bribes will be struck off the doctor roll. In some parts of China, it is announced that those who report this practice to the government can receive a reward worth thousands of yuan, while the doctors concerned will be dismissed. However, despite these kinds of measures, it seems the hongbao tradition is entrenched and likely to die a very slow death in China.

Here’s a little larger, current context for the hongbao practice:
Under the Knife — Why Chinese patients are turning against their doctors

Violence against doctors in China has become a familiar occurrence. In September, 2011, a calligrapher in Beijing, dissatisfied with his throat-cancer treatment, stabbed a doctor seventeen times. In May, 2012, a woman attacked a young nurse in Nanjing with a knife because of complications from an operation performed sixteen years earlier. In a two-week period this February, angry patients paralyzed a nurse in Nanjing, cut the throat of a doctor in Hebei, and beat a Heilongjiang doctor to death with a lead pipe. A survey by the China Hospital Management Association found that violence against medical personnel rose an average of twenty-three per cent each year between 2002 and 2012. By then, Chinese hospitals were reporting an average of twenty-seven attacks a year, per hospital.