One year in Guangzhou!

Happy new year!!  We are starting year 2 in Guangzhou.  My family deserves credit for putting up with many harships and frustrations - even as we enjoy the overall good QOL in Guangzhou. 

Trump and North Korea:   It’s like watching a train crash in slow motion.  From “over here” next to North Korea but in a country with some influence and perhaps some understanding of what is really going on there, I imagine it is easier to see my own country at risk.  At the very least, North Korea is an enormous distraction.  Diverting the attention of our military and parts of our government.  Using much of our geopolitical influence to ask everyone else to try and reign in this tiny country. 

The China strategy seems to be to ignore the internal politics of all countries equally.  They are interested in trade and an opportunity to export their ability to design and deliver huge infrastructure projects – now that the domestic economy can no longer be poweredthis way.  They are willing and able to invest billions in infrastructure projects that enable local economic development which naturally orients toward the country and the people who brought them the railroad, the port, or the refinery. 

I am not finished deciding how I feel about this somewhat “amoral” approach to international relations.  “The Chinese Way” has brought opportunity to millions of people in places we can’t seem to penetrate.  At the same time, they steadfastly refuse to get involved in the judgement of unsavory leaders and regimes.  Are we doing so much better?  The US tries to pick “winners” and makes a big fuss over “defending liberty” and protecting human rights.  Those are worthy causes to be sure, but on balance over the past 20 years, have we succeeded in advancing those causes?  Are people in Columbia, Iraq, and Afghanistan better off?  What helps more:  moral leadership or economic development?

Healthcare: On the domestic, medical front there is another train crash that I am watching in slow motion:  the Chinese public health care system.  I have outlined some of the struggles in previous posts.  None of them are unfamiliar to us in the US.  Overtesting, overtreatment, lack of trust, poor health literacy, worship of technology, demoralized doctors and nurses, nearly absent primary care.  My challenge is to teach what I can, without getting too preachy and losing my audience.  I know some very wise and knowledgeable people who insist that changing the costly behavior of doctors (and it really is mostly in our purvue) is not all about money – but really, let’s call a spade a spade.  I am all for professionalism, satisfaction, joy, etc, but how many people reading this would choose to cut their income by 20-30%, while creating difficult conversations with patients who want technology and their problem fixed NOW and watch the guy or girl in the next office suite doing well operating on anything that moves (and has insurance) while the hospital fawns all over them?

Doctors are highly trained professionals who go to school and train for a decade or more after college, work long hours and sometimes (or always, if you work, for example, in the ED, OR, oncology ward, Labor and Delivery) cope with very upset people in very stressful situations.  They expect to earn enough to keep their families solidly in the upper middle class.  That doesn’t mean exactly the same thing to everyone, but I think most feel they should be able to live in a comfortable community with access to good schools when their kids are young, be able to afford to send their kids to college, and retire at a reasonable age.  They expect comparable earnings to lawyers who also work hard and have challenging work interactions at times.  In the news we see the highly successful folks who work in finance and who grow businesses from scratch to billion dollar exits.  We think everyone with an MBA makes that kind of money. 

Another part of the puzzle is the payment system.  Basically, in the US, CMS and the AMA’s RUC sets payments for 95% of the services for 95% of patients.  Yet, we continue to insist that medicine is a “free market”.  Huh? What kind of free market has fixed payments? 

If a doctor feels entitled to something between 200-300k/year (pre-tax) then they will figure out how many procedures and office visits it takes to get them near their goal.  Note that this is not hugely different between those in true private practice and those who are “employed” by larger organizations.   Most of these “employed” docs have a “salary” that is fairly tightly tied to productivity.  This reality is easy to spot.  Studies show that the number of procedures done in a community is largely dependent on the number of doctors who provide that procedure.  If you reduce the reimbursement for a service, doctors respond by doing more of them and spending less time on each one. 

Anyway, this same incentive system and expectation system is driving the same trend to joyless, thoughtless, expensive, overtesting and overtreatment here in China.  But I believe we need to acknowledge that we can’t fix the process of medical services and then expect doctors and hospitals to behave as if prices are a function of equilibrium in a free market. 

Enough pontificating for now.  Stay safe everyone. 

The new old year ended on a sad note.  Daniel our 16 year cat finally went to that big, clean, litterbox in the sky.  Loren adopted him from our back porch after he showed up there yowling with a torn ear, herpes bronchitis and an eye infection.  He had lost another fight and clearly was't cut out for a life on the street.  Conveniently for her, she was pregnant (!) so I had to take care of Daniel for the first several weeks.  He was affectionate, demanding and not MENSA material, but he was always with us and always purred louder than he yowled.  He got along with all of our other human and four-legged family members.  He was famously beloved by our white ferret Pinky - we think Pinky thought he was a relative.  Anyway, we will miss you Daniel. 

The new old year ended on a sad note.  Daniel our 16 year cat finally went to that big, clean, litterbox in the sky.  Loren adopted him from our back porch after he showed up there yowling with a torn ear, herpes bronchitis and an eye infection.  He had lost another fight and clearly was't cut out for a life on the street.  Conveniently for her, she was pregnant (!) so I had to take care of Daniel for the first several weeks.  He was affectionate, demanding and not MENSA material, but he was always with us and always purred louder than he yowled.  He got along with all of our other human and four-legged family members.  He was famously beloved by our white ferret Pinky - we think Pinky thought he was a relative.  Anyway, we will miss you Daniel. 

OK, any guesses on this food item?  I think of myself as someone who will try almost anything and even like the taste of most things.  I have had bugs and worms and pig fallopian tubes in China.  None were inedible and some were good.  These however, will not be on my list to try again.  I will give you a hint:  they are not bugs or worms, and they are animal, not vegetable. 

OK, any guesses on this food item?  I think of myself as someone who will try almost anything and even like the taste of most things.  I have had bugs and worms and pig fallopian tubes in China.  None were inedible and some were good.  These however, will not be on my list to try again.  I will give you a hint:  they are not bugs or worms, and they are animal, not vegetable. 

I think I may have mentioned before how cool the snails are in Guangzhou.  I love how this one picked up some grass and used it to adorn his tail. 

I think I may have mentioned before how cool the snails are in Guangzhou.  I love how this one picked up some grass and used it to adorn his tail. 

China Daily Article

Very pleased to get a chance to talk to 李文芳 (Li Wenfang) from the China Daily about health care in China and what I see myself as doing here. (http://www.chinadaily.com.cn/china/2017-06/02/content_29587415.htm)

China Daily 2017/6/2

Trip to Xishuangbanna

Month 7 at GWCMC.  We have passed  the six month mark! My parents were here for a 10-day  visit. It started in Hong Kong where we had wonderful dinner of Peking duck and great conversation with one of my father’s college singing friends Ken Fung. It happens that when I was in China 30 years ago, my parents also visited Hong Kong and visited Ken.  I flew to Hong Kong to meet them. In the  30 years that have passed many of his children have gone  to school in Boston and amazingly, his son in law is the son of a well-known OBGYN in Newton.  A doc that I had actually met and whose patients I have taken care of.  The world is small sometimes. 

Hong Kong is an interesting foil for Guangzhou. The geography is quite different, more like San Francisco.  There are clearly many more non-Chinese, and a very different culture. Because we had to bring my parents back to Guangzhou after dinner, we hired a van that was capable of crossing the “border” between Hong Kong and the rest of China. That in itself was a fascinating trip. The border crossing was quite perfunctory. It reminded me very much of the experience of traveling to Canada and back.  We had a very interesting discussion with our driver about how many people in Hong Kong have very different views of the increasing control that the Chinese government is exerting over Hong Kong. He describes that it has in extreme cases led to divorces and much family acrimony.

The next day, we left for a five day trip to Yunnan Province.  We traveled to an area in the south of Yunnan that was a very close to the northern borders of Thailand, Laos, and Vietnam called Xishuangbanna. 

The pool patio of the Anantara Xishuangbanna resort.

The pool patio of the Anantara Xishuangbanna resort.

 

I was struck by the penetration of significant infrastructure development and urbanization.  Like many places, there were certainly situations where the development appeared to be having a significantly negative effect on unique human cultures and very rich natural environments.  There are more Chinese minority peoples who make their home in Yunnan province than anywhere else in China. The largest of these is the “Dai” people who we learned are closely related to the folks who migrated south during the growth and development of Thailand (“thai”, “dai” get it?)  as an independent culture and nation. The visit to a Dai village was one of the highlights of the trip.  We had a wonderful meal of traditional Dai cooking.

Lunch on the ground floor of a traditional Dai house.  In the background, our guide's mother removes the kernels from large ears of feed corn - while her sister talks on her cell phone...

Lunch on the ground floor of a traditional Dai house.  In the background, our guide's mother removes the kernels from large ears of feed corn - while her sister talks on her cell phone...

The people we met more modern in many ways, but they clearly also have a strong connection to their roots as rainforest dwellers. The food was suffused with very interesting and delicious herbs and vegetables. In addition we visited the tree that is still considered the focal point of the village life. Our guide said that the tree may be more than 1000 years old and by the look of it that is not hard to believe! She describes that they have some idea of its age because there are oral histories that describe events known to have occurred more than 1000 years ago that mention the presence of this tree.

The ancestral tree of the Dai villiage we visited.  It is reputed to be more than 1000 years old.  It looks like it could be!

The ancestral tree of the Dai villiage we visited.  It is reputed to be more than 1000 years old.  It looks like it could be!

 

 

After that, back to the Pearl River Delta mega-city.  Thanks to an introduction provided by our family friend Susan Rockefeller, we were invited to tour a large,  vertically-integrated shirt factory in one of the smaller cities about 1 hour from Guangzhou.   Esquel is the brain-child of Margie Yang.  It is a profitable, privately heldbusiness with more than $1,000,000,000 in annual revenue.  Esquel invests a significant amount of capital and time to providing a nurturing work environment for their 50,000+ employees as well as working to make their manufacturing as sustainable as possible from an environmental point of view.  As a result, their employee turnover is extremely low, and they make shirts for more than 20 highly recognizable brands. 

The water treatment plant at Esquel garment factory

The water treatment plant at Esquel garment factory

 

At GWCMC, The CEO’s vision is to go all-in as an academic medical center.  The principal prizes are research projects/programs mature enough to support National Natural science foundation (think Chinese NIH + NSF) Every clinical specialty is tasked with developing in this way.  Every faculty member is expected to participate in research and publication.  There is a big focus on impact factors as a measure of publication quality/success.  I didn’t know that much about it before, but now I can see that its quantitative nature has its allure.  Unfortunately, it also has its problems as a measure for individuals and/or individual publications.  More recently, a big scandal broke as one online, open access journal was forced to retract more than 100 papers simultaneously.  Almost all were from Chinese authors and institutions.  It seems that there was a very widespread fraudulent system of fake reviewers for papers.  It was described that authors would submit plausible reviewers for their papers but give an email address that actually belonged to one of the authors of the paper who then wrote a very positive review.  The fact that so many different institutions participated reflects poorly on the quality of chinese medical science at present.  That is unfortunate for all of the seriously talented, professional and ethical work that is being done. 

 

Well, I think that is enough for now.  I will write again when it had gotten really hot in humid here in Guangzhou.