China: the next frontier.
It’s the talk of the international community: a country of unsurpassed growth, truly the next land of economic opportunity. A country with a history steeped in thousands of years of tradition, turmoil and reform – it makes for an exciting place to do a clinical elective. This article will outline my experience on an elective there, and how you can go about scoring the elective of your dreams.
Source: Zhang Zhang (张涨）on WikiCommons
Part 1: My Experience in Shanghai
1. Getting the position
I really wanted to do an elective in China and had been emailing people everywhere about getting the right contacts. I emailed my old professors, talked to friends of mine with family in China, emailed random organizations in the hopes of finding someone who would get me an “in” (see Part 3: Getting into a Chinese Elective Position). Finally, one of my former professors mentioned to me that he knew someone in the Shanghai Public Health Bureau – and the lead was a go. My contact in China was the Chief of the Pudong New Area Public Health Bureau and was a good connection of my former professors. My schedule was 3 weeks long, and after some tweaking and negotiating, he offered me to spend 2 weeks in a hospital, 1 week in a community health clinic and 1 week in a rural village clinic.
2. Arriving in Shanghai
Shanghai is a giant city. On arrival, I was immediately struck by the diversity of the people. There are plenty of English-speakers in Shanghai, and it’s virtually impossible to not encounter foreigners, let alone English-speaking Chinese.
Shanghai is truly China’s world-class city, and this is reflected in every 5-star hotel and high-end shopping centre that graces the streets. Another thing that struck me was the sheer accessibility of the transit system. In preparation for the World Expo, Shanghai’s subway network has expanded dramatically and 2 new lines were opened within the last year. Getting around in Shanghai is extremely easy.
3. First week at People’s Hospital
I spent my first week in the People’s Hospital of Shanghai – a second-tier hospital in the very north of Pudong, near the Pudong Airport. I spent 3 days working in general surgery, where I was placed with a hepatobiliary surgeon. Here I got to see Endoscopic Retrograde Cholangiopancreatography (ERCP), laparascopic cholecystectomies, and appendectomies by the dozen.
4. Second week at China East Hospital – Obstetrics/gynecology
The next week, I was transferred to a more central hospital, the China East Hospital in Pudong. China East Hospital is also a second-tier hospital right at the heart of the Pudong financial district – in fact it’s right across from the Shanghai Stock Exchange. The hospital has three tiers of clinics stratified by price. If you have a great deal of expendable income or a great international health insurance plan, you get treatment in the International Clinic, where wait times are virtually non-existent and any tests, including CT scans, can be done right away. If you have slightly less money, you will probably seek treatment in the “VIP Clinic”, where you might have to wait, but treatment is still quite fast. Finally, if you’re the run-of-the mill Chinese, you will probably go to the regular clinic, where treatment is much cheaper, but wait times are completely unpredictable, and you have to sign up early in the morning to get a waiting spot for that day!
The first part of my second week, I worked with Dr. Liu, a Reproductive Endocrinology and Infertility specialist. Dr. Liu and I shuttled between the International Clinic and the VIP Clinic in the Shanghai East Hospital, seeing patients in both. It was extremely rewarding to help so many women get pregnant, and you could see the gratitude from women whose visits varied from another round of hormone injections to prenatal checkups. The equipment in these clinics were state-of-the-art – they had a $50,000 transvaginal ultrasound for pregnancy confirmation, for example, that is still not available in many hospitals within Canada. What I learned from those few days was that excellent health care awaits you in China – if you have the money.
I spent the second part of Week 2 in the general outpatient clinic. There the situation is very different. Patients are interviewed in rooms crowded with nurses, medical students, and other curious patients poking their heads through the door. There is very little privacy for pelvic exams besides a curtain, and doctors are very rushed to get through the enormous number of patients they have to see within their shift. Tests are paid for before they are ordered, and patients run back and forth between the doctor’s office and the hospital payment department with receipts for paid tests, like ECGs (US $3) and blood work (US $2.50).
5. Lectures at the Shanghai Reproductive Health Research Institute
While I was working in the clinics and having a fantastic time in the OR, I also wanted to pursue my interest in education and public health. I had a friend from a public health research institute in Yunnan Province who was now working at the Shanghai Reproductive Health Research Institute. Given that I had experience doing public health-related systematic reviews, she invited me to come give a lecture at the Research Institute for the graduate students. It was extremely interesting to meet Chinese public health research students and work with them in this regard.
6. Third week at China East Hospital – Emergency Surgery
The weeks kept getting more and more interesting. In the third week, I was placed with Dr. Chen in Emergency Surgery. In China, this is considered a specialist clinic by itself, and patients can directly see these specialists to fix fractures, appendixes, gall bladders, and any other emergent surgery. The mornings would start off with rounds, with over 20 doctors rounding through the hospital rooms, where 5-8 people would crowd into each room. Then outpatient clinics would start, where we would fix lacerated fingers, clean head wounds, and advise patients on fractures. Then, if there were surgeries scheduled for the day, I would scrub in and assist. I befriended a couple of medical students while there – there were quite a few that would also observe clinics with me.
Part 2: Getting into a Chinese elective position
Before you start looking for an elective, it’s very important to establish clearly why you want to do an elective in China. This is important so that you can articulate why you want to go, but more importantly, it helps you establish why this is useful for your clinical career.
Some questions you might ask yourself are:
- Cultural competency: Have you ever been to China before?
- Language competency: Do you speak any Mandarin? If you go into the bigger cities, many people will speak English; however, my experience is that at least conversational Mandarin goes an infinite distance towards your education. Do you know any medical Mandarin?
- Adaptability: Have you ever done work abroad or had to adapt to new cultural climates? This can have a big impact on how much you enjoy your elective.
What if you don’t know Mandarin?
Don’t worry, you can probably still go! You’ll likely be limited to larger cities like Beijing and Shanghai. The good news? The hospitals that harbor English-speaking staff will most often be the tertiary academic hospitals – just the ones where you’re probably most interested in working.
2. Qualities that will make your time much more effective
Know your limits. If you’re not comfortable doing a procedure, you must speak up and tell them you’re not comfortable with it. While scrubbing in for my first appendectomy, I was asked whether I wanted to make the first incision. Although my initial thought was “of course!”, I knew I wasn’t prepared, and politely declined, telling the surgeon to show me the proper way of proceeding so I could learn for next time.
Be flexible. If you’re not coming as part of a fixed program, your schedule is likely to change at any moment. Be sure you’re able to deal with these changes and adapt your learning schedule accordingly. I was also not informed of several very major holidays that came up during my time there, and therefore had a lot of time off.
3. Visa Requirements
[Note from the editors: The Lancet Student does not take responsibility for the accuracy of the information provided in this section]
Entry to China requires a visa. The easiest way to go about this for shorter electives (90 days or less) is to apply for the Tourist visa, which grants you between 30-90 days in China. To apply, you will need your passport, a completed application, and a passport-size photo. Visas will usually be issued within 5 business days, but rush orders may be placed for same-day or two-day completion. Students interested in staying in China for longer periods of time may need to apply for the Student visa, which requires a more extensive process requiring a letter of admission from the Chinese college or university, and a complete medical check-up. Confirm with the closest Chinese consulate or embassy in your country for details.
International health programs at your university. North American universities generally have very well-established international health programs with other universities – yours might have a good connection with China. Look beyond just the traditional and general “Global Health Program” – try looking for opportunities to travel with non-medical groups, or groups with specific medical interests that are different from yours.
Contacting professors who work in China. Keep your eyes open for health projects featured in your local medical newsletters/newspapers. If there is something that interests you, contact the professors directly. How about your old professors? One of my old professors was the key to helping me find my elective in China.
International health programs at other universities. Believe it or not, some schools may allow medical students from other universities to participate in their international health programs. Check individual school websites for details.
Your own contact list: With the boom of emigration from mainland China to many western countries, you may well know of someone who was formerly a doctor in China. These are fantastic people to contact, as they will likely have colleagues in China who may be able to help you arrange an elective.
Bottom line: In China, it’s all about who you know. If you’re able to get a good contact, doors open substantially to you.
Part 3: Lessons for my work in Canada
I study in Vancouver, Canada, where there is an extremely large immigrant community. My first rotation of clerkship was in Emergency Medicine. While there, I was constantly surprised at how many people were non-English speaking, Chinese recent immigrants. Every day, I was able to help out with translation, often being the only staff member able to take an adequate history from the patient.
One particularly memorable case reminded me of the necessity of competency in cross-cultural medicine. One day, my supervising doctor told me to get ready – a man was being helicoptered in after being found down on the side of a rural highway. When he came in, it turned out he was Chinese, didn’t speak a word of English, and had no family in Canada. The ECG indicated a new anterolateral myocardial infarction. I was the only person there who could speak Mandarin, so I immediately put my new-found Emergency Medicine interviewing skills to use, and took his medical history in Mandarin while he was wheeled up to the cath lab to have an emergency stent placement. With a clot blocking one of his coronary arteries, every second was crucial, and being able to explain the catheterization and stent placement procedure quickly to him in Mandarin and obtaining his consent was very important in making sure he received the most timely care possible – and possibly save his heart of some ischemic damage. He asked plenty of questions as well, which I tried my best to answer (or field to the right person), and I’m sure helped ease the tension when several doctors started threading a large catheter up his leg. Being there to help was extremely rewarding given that my knowledge of Mandarin contributed to this man’s care – thanks to my elective in China.
Medical student, University of British Columbia, Canada.