In the eyes of many, Chinese clinicians lead the world in clinical experience due to the sheer volume of visits and surgeries. He Jie, an expert in thoracic surgery and an academician of the Chinese Academy of Sciences, has publicly stated that the amount of surgery performed by a young doctor in China in a year is almost the same as the number of surgeries performed by some foreign doctors in a lifetime. Visual China | fig
After 30 hours on duty, Kou Xiao, a 30-year-old cardiologist, made a decision to become a doctor abroad.
"I decided to fight the midlife crisis in this way." In Kou Xiao's plan, he needs to prepare for the United States Medical Licensing Examination (USMLE) first. After passing the exam, you will further obtain ECFMG certification, and then apply for residency training in the United States, which will lead to a U.S. medical license.
Today, there are very few Chinese doctors who have taken this path. According to the American Medical Association and the Council on the Education of Foreign Medical Graduates (ECFMG), the total number of Chinese medical school graduates practicing medicine in the United States was 5,355 in 2017, an average increase of 147 per year since 2007.
In fact, compared with medical devices, Chinese herbal medicines, APIs and even innovative drugs, China's medical services are still limited to the domestic market for a long time. According to the 2023 National Economic and Social Development Statistical Communiqué, at the end of 2023, there were 4.78 million licensed physicians and licensed assistant physicians in China.
Li Yang, a public health scholar who has studied the medical industry overseas, told Southern Weekend that Chinese doctors are already competitive around the world in terms of ability, "especially in clinical practice." Due to the large population base and the large number of patients visited, Chinese doctors are very experienced in differential diagnosis and surgical operations."
Since 2023, a group of practitioners in the medical industry have tried to send Chinese doctors abroad. A hospital in Dubai, UAE, which will open in late May 2024, plans to recruit medical staff from China; The Chinese director of a hospital in Ethiopia is also negotiating cooperation with a domestic doctor group, hoping to invite Chinese doctors to perform surgery.
They face a series of obstacles: compilation constraints, language barriers, barriers to entry, and so on. Can this untouched path be passed?
Investment in the establishment of institutes and the export of technology
Before investing in the hospital, Guo Jianhuan's main identity was the chief representative of the Essa Al Ghurair Investment Group in China. It was his first foray into the medical industry, but it didn't slow down the start of the hospital.
In September 2023, Guo Jianhuan visited Thumbay Hospital, which is interested in selling. In November, Gulal Group acquired Thumbay Hospital from the original Indian seller and renamed it Chung Hwa Hospital, with Guo Jianhuan as the vice president. At the end of May 2024, the hospital will begin trial operation.
At first, the new hospital was named "China Hospital" and later "China Hospital". "Because we serve not only Chinese, but also Chinese and overseas Chinese in various countries." Guo Jianhuan told Southern Weekend.
On the map, the hospital is located 3 km from Dubai International Airport and is built in several white buildings. Although there are only 110 beds, Guo Jianhuan hopes to build 29 departments according to the standards of a general hospital, of which about 60% are Chinese. Key positions such as the director and head nurse are also held by Chinese.
Also noting the prospect of overseas medical services is Dr. Zhang Qiang's group. Dr. Zhang Qiang Group is the first doctor group in China, founded in 2014 by vascular surgeon Zhang Qiang. In December 2023, the Group's first overseas phlebiology center was inaugurated in Addis Ababa, Ethiopia. Previously, the group's doctor Deng Jianping carried out the first CHIVA surgery in Africa, which is a minimally invasive surgery for the treatment of varicose veins introduced in China.
Unlike investing in the construction of physical hospitals, Zhang Qiang chooses to export technology and experience. He plans to lease space in the United States, Japan, Australia and other countries to set up phlebopathy centers, where Chinese doctors are mainly responsible for business management and training in CHIVA surgery, and local doctors who work part-time will operate on the job. This not only saves costs, but also saves the trouble of obtaining a doctor's license.
"At present, there are already chain venous clinics in Australia and a number of American doctors who have expressed their intention to cooperate. In May we will go to Japan for an inspection tour and in October we will go to Italy. Zhang Qiang told a reporter from Southern Weekend.
Wang Jianhua, director of Silk Road General Hospital in Ethiopia, is also looking to work with more Chinese doctors. The hospital, which opened in 2019, has taken the route of "small general, large specialty": several specialty departments are run by foreign doctors hired by high salaries, while other minor departments are run part-time by local Ethiopian doctors, also to save costs.
On the basis of undertaking the first overseas surgery of Dr. Zhang Qiang Group, Wang Jianhua hopes to replicate the success - cooperate with other domestic doctor groups to build a department. "After our DSA (digital subtraction angiography) arrived, I wanted to communicate with a group of cardiologists in China. In terms of obstetrics and gynecology contracting, we will discuss the possibility of cooperation with a group of obstetricians and gynaecologists. ”
Clinical experience "far ahead"
"For some areas with scarce medical resources, China's medical resources are high-quality and cost-effective." Guo Jingtao, deputy director of the Institute of Social Medical Institutions at Shanghai Jiao Tong University, told Southern Weekend.
Clearly, in this gap, Chinese doctors and healthcare investors can find room to play their part.
As early as 1963, China sent the first Chinese medical team to Algeria in North Africa. The National Health Commission disclosed at a press conference in 2023 that in the past 60 years, China has sent nearly 30,000 foreign medical team members to 76 countries and regions, helped build more than 130 medical and health facilities, and treated nearly 300 million patients.
In 2006, Wang Jianhua, who was also the attending doctor of a county-level hospital, joined the medical team and was assigned to the southern state of Ethiopia. Wang Jianhua recalled to Southern Weekend that there are almost no surgeons in the region, which has a population of more than 1 million. That year he performed 600 surgeries, half of which were for acute intestinal obstruction. Until then, local patients with severe intestinal obstruction had to wait at home to die.
"There are many doctors like me in China, but having one more doctor here is very helpful to them." With this in mind, in 2008, Wang Jianhua and his lover, who is a radiologist, founded an imaging diagnostic center in Ethiopia, and 11 years later opened Aifei Hospital.
Compared with Wang Jianhua's aid to Africa, China's medical level has continued to improve since then. In 2018, The Lancet, an international authoritative medical journal, ranked the quality and accessibility of medical care in 195 countries and regions around the world. China's ranking has risen from 110th in 1995 to 48th in 2016, making it one of the most improved countries in the world.
In the eyes of many, Chinese clinicians lead the world in clinical experience due to the huge number of visits and surgeries. He Jie, an expert in thoracic surgery and an academician of the Chinese Academy of Sciences, has publicly stated that the amount of surgery performed by a young doctor in China in a year is almost the same as the number of surgeries performed by some foreign doctors in a lifetime.
Seeing this potential, Guo Jianhuan hoped to introduce a team of experts from the affiliated hospitals of top medical schools in China at the beginning of the preparation of the hospital. They either sit full-time at Chung Hwa Hospital, or fly to Dubai regularly in the name of the "Chinese Famous Medical Group" to teach and perform surgery. In April 2024, five doctors, including Lin Jianjiang, an anorectal surgeon, and others will carry out free clinics at Zhonghua Hospital, all of whom are retired experts with a background in Zhejiang University School of Medicine.
On February 23, 2023, at the Diam Niaghu Children's Hospital in Senegal, Guo Lianghua, an internist of the 19th batch of China's medical team to aid Senegal, bumped fists with the children. Xinhua News Agency fig
To find a patient, the Chinese are the first choice
Different from foreign aid medical treatment, the commercial rate of return and feasibility must be considered when setting up a hospital or practicing medicine abroad. This requires them to find the target patient group, and overseas Chinese are the easiest answer to think of.
As a consortium in the Middle East, the UAE Gulal Family Investment Group named its new hospital after "Chinese Hospital", which is precisely to see the huge local Chinese medical market in the UAE.
On November 11, 2022, Chinese Ambassador to the UAE Zhang Yiming said in an interview with the Arab News Agency that as of 2022, the number of Chinese expatriates in the UAE has increased to as many as 400,000, accounting for 4% of the total population of the UAE. At the same time, more than 400,000 Chinese tourists visit Dubai every year.
Despite their large numbers, their medical needs remain unmet for a long time. Guo Jianhuan said that in the past, Chinese medical institutions only opened small clinics. The quality of hospital services run by multinational medical groups is also unsatisfactory. A Chinese colleague at Guo Jianhuan's family investment group had a simple gallstone operation a few years ago, which cost more than 200,000 yuan.
The team of the Center for Global Health Governance at the Institute of Regional and Country Studies at Sun Yat-sen University has consulted on a number of Chinese-funded hospital projects that are interested in landing in Africa. A team member told Southern Weekend that a state-owned enterprise had planned to build a hospital in Angola and recruit doctors from the country. Angola is the fastest-growing region in Africa, reaching 200,000 in 2017.
According to the member, to investigate whether a country is suitable for investing in hospitals, the first step is to look at the country's disease burden and medical level, and find unmet medical needs. The market size is then derived by evaluating the ability of the patient group to pay through the income structure and insurance coverage.
Even in economically backward Africa, business opportunities can be identified. The team found that the Angolan government has no control over the price of medical services, and medical institutions enjoy more freedom of pricing power, with some private hospitals charging as much as US$80 per visit. For example, nearly 10,000 people in Kenya travel to India every year for medical treatment, and a third of them are for cancer-related treatment. If this population can be kept in Kenya, the annual market size for cancer treatment could reach $44 million.
Even in developed countries, there are shortcomings and gaps in the medical industry. Daniel Zhang, director of the Somerville Medical Center in Australia, told Southern Weekend, "In the Australian countryside, some people have to drive more than 300 kilometers to see a doctor, and some people have to wait more than a week to see a family doctor, and finally can only see a nurse, because doctors have no time." Therefore, Australia needs a large number of doctors, which is just needed. "In recent years, in order to solve the shortage of doctors in remote areas, Australia has allowed applicants to complete a one-year internship in a private health care facility, followed by family doctor training.
Daniel Zhang graduated from Xi'an Medical University (now Xi'an Jiaotong University School of Medicine) and worked briefly in a public hospital in Shaanxi. In 2001, he resigned and came to Australia to study. After graduating with a master's degree, he completed his training at a local hospital and became a family doctor, and later opened a clinic, currently employing 6 local Australian doctors.
Patients and their families wait at the Diamniaju Children's Hospital in Senegal on March 21, 2023. Xinhua News Agency fig
Access is the biggest threshold
For a Chinese doctor who wants to practice in the United States, the door to USMLE is open. The exam is similar to the medical qualification examination in China, but there is no restriction on nationality. Graduates of medical schools recognized by ECFMG (including almost all medical schools in China) are eligible to participate.
Kou Xiao said that USMLE has set up test centers in China, and the test time is flexible to make appointments. However, due to the high difficulty, long cycle, and high cost, and once it fails, it will lead to a greatly reduced success rate of residency training, so candidates often spend years preparing, and in the end, very few persist.
At the beginning, Kou Xiao, who claimed to be good at English and had worked as a translator in a United Nations peacekeeping mission, couldn't even understand the questions in the most basic question bank, "I read five questions for a week." For two years, he studied for more than 12 hours a day, until the medical terms blurted out became English, and all the knowledge points formed muscle memory.
Obviously, this rugged path is not universal. In the face of insurmountable access difficulties in Europe and the United States, institutions interested in running medical services overseas have naturally turned to countries with scarce medical resources and more relaxed policies.
Wang Jianhua said that in Ethiopia, foreign doctors only need to have their licenses notarized by a notary office, and then sent to the consular department of the Chinese Ministry of Foreign Affairs and the consular office of the embassy of the host country for notarization and sealing, a process known as "double certification". The situation is similar in Angola, where Chinese doctors have their domestic medical licenses notarized in English and Portuguese, approved and stamped by the Ministry of Foreign Affairs, and reported by the Angolan Health Bureau, without the need for an examination.
The UAE is also taking the initiative to lower the threshold. In January 2024, the Dubai Health Authority announced the launch of the "Dubai Practice License" program, according to the Emirates News Agency. The permit can be processed in as little as one day, which is equivalent to a temporary exemption from practicing medicine. "Doctors can start practicing medicine directly when they come to Chung Hwa Hospital, and then they will take the medical license exam a year later, during which we will arrange training." Guo Jianhuan said.
The cross-border recognition of a doctor's license is like a tourist visa, which is neither reciprocal nor equal. Daniel Zhang mentioned that British doctors who come to Australia to practice only need to be certified by the authorities, unlike Chinese doctors who need to take exams. Kou Xiao also said that in some high-end private hospitals in China, there are a large number of foreign doctors serving foreign patients, who only need to file with the National Health Commission to practice, but it is difficult for Chinese doctors to practice medicine in the United States.
"The more developed countries have higher prices for medical services, the higher the access requirements for doctors, and the two are directly proportional." Guo Jingtao believes that there will not be a large number of Chinese doctors going to Europe and the United States in the short term.
Establishment, money, liberty and honor
For doctors in public hospitals, resignation means giving up the establishment, and all the material rewards and promotion opportunities associated with it. This is one of the important reasons why it is difficult for overseas hospitals to recruit doctors in the system.
In the Angolan medical research report, the Sun Yat-sen University team envisioned some ways to solve this problem, such as building a research hospital, inviting doctors from domestic medical schools to come for consultation, and giving them the opportunity to do research to solve the problem of promotion in China.
But there are also people who want to leave the system on their own initiative. Guo Jianhuan interviewed several "century-old leaders" who could not be promoted to deputy senior titles for more than ten years due to various reasons. "There was an orthopedic surgeon talking to us, saying that he had done a lot of work, and the relationship with the leader was not good, and I thought he was about to burst into tears."
Can practicing at sea become a new choice for these doctors?
From a material point of view, the answer seems to be yes. Guo Jianhuan paid a department head a monthly salary of 50,000 dirhams (about 100,000 yuan), about 30 percent higher than the latter's domestic income. Such an increase may not seem high, but he said that in the future, hospitals will establish a performance incentive mechanism, coupled with Dubai's tax exemption policy, and the income will be more considerable.
However, in Li Yang's view, the income of domestic private hospitals for big experts is already very considerable, and the material rewards brought by overseas medical practice are not necessarily more attractive than letting people leave the familiar environment and family.
As a pioneer in going overseas, Aifei Hospital has not yet hired a single Chinese doctor. Wang Jianhua explained: It is difficult for doctors in ordinary hospitals to be competent in language and other abilities, and doctors in hospitals above the third level have sufficient ability, but the treatment requirements are high, and they are not willing to go to sea.
There are also some advantages that money cannot measure, such as the freedom to choose a job and change jobs, as well as the freedom to choose the intensity of work. Before the pandemic, Daniel Zhang worked only 28 to 30 hours a week, spending more time with his family. He also advised other doctors who want to come to Australia not to take income too seriously, "always remember the original intention, serve the interests of patients, and gradually live a decent and comfortable life".
Of course, sometimes the top doctors with fame and fortune have little interest in making money. When trying to convince a retired expert, Guo Jianhuan offered an honorary plaque: "Go to Dubai, you have a new starting point in life, and this starting point can make you a monument." In 30 years, when your grandson goes to Dubai, he may see a monument that reads, 'The first batch of Chinese medical experts to go to sea'. ”
After nearly three years of struggle, Kou Xiao passed the USMLE exam in July 2019 as he wished, but finally did not go to the United States for various reasons. After that, he continued to engage in teaching and clinical work in a tertiary hospital. Kou Xiao believes that the examination experience of USMLE has provided him with different ideas for clinical diagnosis and treatment, and has also allowed him to seamlessly connect when teaching international students, "in a sense, I have also realized my desire for transformation."
(At the request of the interviewee, Kou Xiao and Li Yang are pseudonyms)
Southern Weekly reporter Haiyang Southern Weekly intern Zhao Yongqi
Editor-in-charge: Cao Haidong