In April 2014 I spent a month with the Department of Surgery at the Affiliated Hospital of Qingdao University – Huangdao Branch. It was a marvelous experience, and I was asked to share a snapshot of my time there.
Qingdao, which means Green Island, is a major coastal city of approximately three million people in the Shandong province of China. The city boasts the world’s longest sea bridge, Tsingtao Brewery, and Lao Mountain. Reminders of its time period under German colonization in the 1800s remain visible in Qingdao’s wide streets and architecture.
View from Lao Mountain |
German Governor's Mansion, a prime example of Qingdao's colonial architecture. The construction was said to be so extravagant that the Kaiser fired the governor once he received the bill. |
The outpatient entrance of the Affiliated Hospital of Qingdao University, Huangdao Branch which formally opened its doors in 2011 (picture source) |
During the week, my mornings started with morning report at seven
o'clock, with rounds following shortly after. The rest of the day would
be spent in the operating theatre. Cases usually began around nine
o’clock, with the occasional earlier start time. Rooms turned over
quickly, and it was not unusual for the team to schedule multiple
gastrectomys and low anterior resections each day (the department of
general surgery was colorectal heavy). Elective cases took place through
the weekend, but I used my Saturdays and Sundays to attend local
conferences, visit a community health clinic, and observe other
services, such as emergency medicine, critical care, neonatology,
pediatric surgery, and hepatobiliary surgery.
Outside the Huangdao Community Health Service Center, where patients can receive preventative care or chronic care management |
An infographic that breaks down the typical appendectomy bill generated from a US hospital (picture source) |
Another observation led to the realization that I have been spoiled by the scrub nurses back at home. In the operating rooms at Huangdao Hospital, everyone with the exception of the attending was expected to gown and glove themselves. Also, every effort was made to conserve and reuse. Gowns, needles, and even the laps used to soak up the betadine solution used to prep the patient were recycled through the system for future use. Face masks and caps are rationed out to those entering the operating rooms by a nurse who stood guard outside the locker rooms.
An additional fascinating discovery was in learning which types of cases were considered too risky for residents to perform independently and which were not. Residents were given exceptional autonomy in performing upper gastrointestinal and colorectal cases, but if a patient needed a gallbladder out due to symptomatic cholelithiasis or choledocholithiasis, attendings and chief residents were the only ones allowed to manipulate the biliary tract during laparoscopic cholecystectomies. The most action junior residents could hope for was to drive the camera. They were shocked when I gave them examples of the types of cases US residents at their similar level were allowed to perform.
Catching a close-up glimpse of a different training structure gave me some added perspective into what mine would soon be in the US. Given the controversy in the states regarding how work hour restrictions have led to an increase in hand-off errors, it was of particular interest to me as a soon-to-be intern to see what life without work hour restrictions looked like. The residents lived in or around the hospital--most unmarried or living separately from their partners and children. Their attention was channeled 100% into become better surgeons each and every day, which showed. The residents in Huangdao were technical wizards in the operating room. They were able to dissect their way into the correct plane in seconds, without a single wasted movement. No bleeder or atypical anatomy fazed them. They knew all the patients front-to-back. Many of my mentors in the US have spoken to me of what surgery was like in the good ol' days without work-hour restrictions. Being in China gave me a glimpse into their past, and it was awe-inducing.
The thing is, the past is almost always seen through rose-colored lenses, and after the initial rosiness died down a bit, I started to better understand the rationale for why residency training in the US has undergone such tremendous changes, even if the changes have resulted in their own challenges. The residents at Huangdao Hospital had little time to stay up-to-date with the literature, spend time strengthening family ties, or maintain interest in meaningful outside hobbies. It was not unusual for residents with families to take the bus into the city to visit wife and child for half a day, spend the other six days of the week in the hospital, and then send as much of their income as possible home to help pay the bills. The residents were at the beck and call of the hospital and their department around the clock. It was only by their good fortune that they had a Chair known throughout the hospital for his fairness and kindness.
My classmate from UTHealth Amy Wang and I with the Chairs of Surgery from each of the three hospital branches affiliated with Qingdao University. Dr. Yun Lu on the far left of the screen, next to Amy, was the Chair of Surgery and our faculty mentor at the Affiliated Hospital of Qingdao University, Huangdao Branch. |
My conversations with the Chair of Surgery were rewarding. I was able to pick his brain on how to become a better leader based on his own his triumphs and tribulations, and he had an opportunity to learn new methods by which he could try to improve the quality of his residents' training. Our conversations were numerous, but one particularly meaningful impact I made didn't require me to make any fancy speeches. My mere presence was enough because it caused people to talk. By April, I had already found out that I would be at the University at Buffalo, the State University of New York for my next half decade of general surgery training. Women pursuing surgery in China is a once in a blue moon phenomenon—essentially unheard of. They were shocked and impressed to find out that I was one of multiple women in my class at the University of Texas Medical School at Houston who matched into a surgical specialty for residency. One circulating nurse rushed home that evening to share the news with her daughter. It was mind-boggling to see the people around me attempt to grasp the concept of a woman not only pursuing surgery but also having that accepted as normal within society. I could see the beginnings of a paradigm shift taking place in many of their minds.
There are so many more remarks I can make about my experience abroad. The 60-70% 5-year survival rate for patients diagnosed with resectable gastric adenocarcinoma at Huangdao Hospital compared to the dismal 30% in the US. The occasional traveler or expatriate who spoke English. The sick patient who still appreciated whatever counseling I provided in my broken Mandarin. The Chinese government's firewall of social media platforms like Blogger, Wordpress, Facebook, Youtube, and Twitter that allow real-time communication to take place, now so heartily embraced by our surgical community. The pay-for-service approach. The paternalism. The around-the-clock walk-in clinic. The heavy reliance on radiographic imaging. The lack of tort reform or Good Samaritan laws. The lateral rigidity in career transfer. The integral role played by family in the perioperative management of patients. There are some aspects of surgery in China that have my utmost admiration, others nothing but frustration. But that goes for most things in life.
Here I am checking up on my patient. No identifying features of the patient are shown out of respect for the patient’s privacy |
I would never have had this opportunity without the mentorship and sponsorship of Dr. Anil Kulkarni, whose recommendation of me to his friend and former colleague paved the way for me to establish my own special project to rotate in China. Dr. Yun Lu, the Chair of Surgery at the Affiliated Hospital of Qingdao University, Huangdao Branch has invited me to return, and I definitely plan to take him up on his offer. Eventually I would like to bring other students along with me to show them how amazing of a profession surgery is, and what a comfort it is to know how quickly and easily it can be for a surgeon or aspiring surgeon to feel at home in any country simply by walking into an operating room.
An aerial view of Qingdao (picture source) |
Have you ever completed a surgical rotation in a country different from your own? If so, what was that experience like? Share in the comments below.
~~~
Jane Zhao is a general surgery resident at the University at Buffalo, the State University of New York. She obtained her medical degree with a scholarly concentration in Clinical Quality, Safety, and Evidence-based Medicine from the University of Texas Medical School at Houston and completed her undergraduate studies in Medicine, Health, & Society at Vanderbilt University. She was the 2012 recipient of the Shohrae Hajibashi Memorial Leadership Award and chaired the AWS Blog Subcommittee from 2013 to 2014. Her interests include healthcare social media, quality improvement, and public health. She can be followed on Twitter.
Inspiring and Encouraging Women Surgeons Since 1981: My International Surgery Elective
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