Universality of "ethics"

Submission for medical ethics class:

Universality of “ethics”

I had the privilege of participating in an overseas elective in China as part of a bilateral partnership between UWO and Huai’an No. 3 People’s Hospital, located in the major city of Huai’an with 6 million people. During the month I was there, I faced a whole new culture, quickly learning how it permeates in all aspects of healthcare: patient-physician relationships, medical training philosophies, healthcare resource planning. 

Allow me to share three memories that have been waiting to be acknowledged and unpacked:

1. Patient confidentiality: is there a role when collective identity is emphasized?

Morning inpatient psychiatry rounds took place in the common room. All physicians rounded at the same time, dispersing themselves among their patients. While doctors had their list of patients to get through, patients were drawn to any person wearing a whitecoat, desperate to engage in conversation. Interviews and mental status exams took place in the midst of crowds of patients. Hands reached out to grasp our sleeves. The concept of personal space did not exist. 

On the peripheries, some patients sat on tables, passively watching. One patient was fully concentrated on crafting beautiful origami baskets with old newspapers, yet she refused to utter a sound when approached by her doctor. Other patients tried to answer for her: “No, she has no appetite,” one would say.  “Doctor,  she hasn’t complained,” another would say. “Hey, the doctor is speaking to you. If you don’t answer him, he can’t help you”, says the one next to her.

It occurred to me that these patients spoke with a culture rooted in the collective identity. They participated in each other’s interviews; they didn’t mind that ten others were listening to their answers to a review of systems, or whether they were experiencing side effects. Furthermore, collateral histories were taken in the doctors’ workroom, with the entire department listening to the interview.

Similarly, at my outpatient clinics both in the Western and Traditional Chinese Medicine hospitals, the door to the clinic room was ignored. You can freely walk in and stand behind the patient currently seated beside the doctor. If you listen in, you may learn some valuable medical advice that can be beneficial to you, or maybe to a person you know who has similar symptoms. In fact, you may have received some previous advice from another doctor, and you can provide some input into the conversation you happened to walk into.

Interestingly, no one seemed bothered or embarrassed. I was the most uncomfortable one observing this obvious breach of patient confidentiality. Thankfully all physical examinations were done in a separate room. I was also surprised at how quietly attentive each crowd was when the doctor gave the diagnosis and/or therapeutic recommendations. 

The unspoken rule: Everyone can benefit. There is nothing wrong with listening in on others’ conversations. Everything the doctor said could be relevant to themselves or someone they knew. With this collective identity ingrained in the Chinese culture, how can a foreigner such as myself insist on patient confidentiality? Is it relevant? Should it be relevant? 

2. Emphasis in mental healthcare: which way is the right way? 

An interesting juxtaposition. In Ontario, psychiatrists boast in our progress in mental healthcare: reduction of stigma and increasing outpatient programs with emphasis on re-integration of our patients into our communities. 

In China, I spoke with two main Directors of Psychiatry: one who is famous in Jiangsu province for her vision and expertise in psychotic disorders, and the other worked in one of the largest hospitals in the major city of Shanghai. Both proudly boasted their statistics respectively: we have a 400-bed, and 1500-bed inpatient psychiatry hospital!

Interestingly, the first director specialized in caring for those patients known as “no name” patients. With China’s 1.3 billion population and ongoing influx of migration from rural areas to cities, it is not surprising that a patient can present in frank psychosis in another city with no clues to their identity or their origin.

The second director interestingly stated his confusion with his recent visit to the United States where he noted the capacity of North American psychiatry wards in a major city: “The largest was only 50 beds. That is too small! Why are they so small?”

I felt the urge to counteract with explanations of the wonderful concept of outpatient care and community interdisciplinary teams. But I stopped myself. 

Canada’s entire population is less than China’s most populated province of Jiangsu. We have enough difficulty in administering sustainable community programs to our small national population. How do you begin to implement similar healthcare structure in a country that has 1/5 of the world’s population? China is looking to the Western countries for insight into shaping their own healthcare system. As much as I take pride in the Canadian system’s values, the sheer enormity of the task to adapt and expand a system fit for 34 million into one that works for 1.3 billion commands respect. And maybe, just maybe, the Western world doesn’t always contain the right answers, and the solutions we have may not always be applicable to the rest of the world. 

I chose to keep my mouth shut. I chose because I had much more to understand and appreciate regarding the differences between China and Canada before I start to make judgement calls as a medical student in training. 

3. Shaping reflective physicians: a waste of time? 

In Canada, we are trained in patient-centered care. At UWO, we are trained to FIFE: ask the patient about their feelings, ideas, function, and expectations. Furthermore, we are trained to evaluate our own feelings and ideas. We are trained to actively reflect on our experiences, to debrief, to talk about our difficult encounters with our teams and peers, to discuss ethical dilemmas, to write papers such as this one. There is an emphasis that we are humans with emotions, and that we have to take care of ourselves so as not to negatively influence the quality of care to our patients.

In my conversation with a young, newly graduated doctor who has since become a good friend, I was challenged with the direction of our medical training. After admitting a patient with quite disturbing delusions and hallucinations, I felt the need to debrief with my friend: 

“Do you find it difficult working in psychiatry sometimes, especially with patients such as this last one?” She replied curtly, “No.” I was surprised at her short answer, so I tried again to open the conversation, “Have you had any patients that have made a strong impression on you, or changed how you work with other patients?”

She gave me the oddest, incredulous look. 

“Lydia, I don’t have time to think about myself like that! I need to study for my exams or work! ”  

At that moment, I fully admit, I felt ashamed at my implied confession that I spent my free time brooding over clinical experiences with my fellow classmates. I worried  that I gave a bad impression of foreign medical students as self-conceited, rich and privileged, who, instead of constantly engaging in self-improvement through studying or working, sits and thinks about... ourselves. There is in fact the possibility that other countries look at ours, scratch their heads and conclude that ethics and reflective training slows down efficiency in healthcare delivery with respect to time and money. 

Internally, I struggled and questioned the benefits of ethics and reflective training.  Is one way better than another? Is there a “right” or “wrong”? Patient confidentiality vs. collective identity? Outpatient vs. inpatient mental healthcare? To reflect or not to reflect? 

In the very exercise of reflecting, I realize that recognition of these differences and identification of internal struggle are evidence that cultural exchange has occurred. Isn’t that one of the main learning objectives of overseas electives afterall? 

I can also confidently declare that this reflection has been beneficial to me. I have returned with a challenge to choose for myself the values that I have been taught as a medical student.  

I can say that if I stayed in Canada to practice, then yes, I agree in patient confidentiality, encouraging outpatient mental healthcare, and the necessity of reflective physicians. However, if I were to practice in China with its unique differences in culture and population, I can also accept that there may be reason to choose otherwise. 

For now at least, I sit well with the conclusions above. 

And most importantly - that is okay.