This post is part of a series we are calling "Best, Wang Shi Kai." Dr. Rich is an Emergency Medicine Physician from Los Angeles who picked up and moved to China where he is currently practicing. He was given the name Wang Shi Kai by the Chinese Medical Board. In this series of posts we feature his emails sharing his unique experiences practicing medicine in China. Here are the links to his first email which gives some background Email 1 Part 1, Email 1 Part 2, Email 2 Part 1, Email 2 Part 2 .

The conclusion of Email 3. Click the link for Email 3 Part 1:

I have a few more observations on the state of Medicine in China.

Chinese culture is based on relationships. Social networks are very important. And it is even more important when it comes to doctor-patient relationships. If you are sick enough to require admission to the hospital, you must have a "relationship" with someone: a doctor, nurse, or CEO, in order to secure a hospital bed, or undergo a procedure or operation. Otherwise, you can languish in the ER for days, with no on willing to accept responsibility for you. A "Red Pocket" bribe, as it is known, may be between 2-10,000 RMB ($300-1600 US). Some hospitals forbid the bribes but in most places they are accepted and expected.

Specialists have rooms or stations set up in the ER and tickets to see these doctors are sold on a daily basis. Some people, you might call them entrepreneurs, make money by lining up early and buying up the allotted tickets (usually around $3-5 US each) to see a particular doctor. Most doctors will sell out of tickets for the day and the "entrepreneurs" will re-sell the tickets to prospective patients for up to $100 each. Quite a nice mark up!

One of my ER nurses developed arm swelling after a tetanus vaccination. It was probably an allergic reaction but she was turned away from 2 different ER's, one because there was no Dermatologist on duty and another because there were no more appointments available (all the tickets had been sold). Obviously, she didn't really need a Dermatologist in the first place!

Another nurse friend of mine went to a local hospital complaining of breast pain. She waited all day to be seen. When it was finally her turn, she was forced to take her shirt off in front of 5 male patients who were standing in line to be seen by the doctor who did not wear gloves to examine her and was eating a sandwich during the exam!

One of our ER Fellows, who is actually a very good, enthusiastic doctor, told me that during her training she was sometimes forced to make up false exam findings in order to justify giving IV medications to patients so that her attending could get kickbacks from the pharmaceutical company. She also told me that her Medical school training was very inconsistent and not evidenced-based. I think the biggest problem that I see is the continued overuse or misuse of antibiotics. Especially in pediatrics. The standard approach to fever seems to be that if it present for more than 2 days and you have an elevated WBC or CRP (anything above the upper limit of normal), then you get antibiotics. It is very hard to convince people that they don't need antibiotics but I won't give up trying! I have begun using the delayed prescription method, asking people to wait 3 days before they fill their prescription. I don't know how many people follow through with the wait period but maybe there will be a few.

Finally, I thought you would get a kick out of some interesting aftercare instructions that one of my Chinese colleagues writes on all his discharges. I had a nurse translate it into English and it reads:

"Return to the ER for worsening symptoms. Adhere to a strict diet of rice, fruit, carrots, and tea. Avoid gastric irritants and spicy food. Live a good life."

Can't argue with that!

Wang Shi Kai