The Yellow River (Huang He) runs through the entire 3-million-metropolis of Lanzhou, the capital of the Northwestern Chinese province of Gansu. The 459-meter-long Yuantong Bridge (on the photo) is the recent addition to Lanzhou’s bridges. However, its landmark is the Zhongshan Bridge, the first permanent bridge over the yellow river in all of China, completed in 1909. It was an early Chinese-German joint venture. Lanzhou is also an economic hub in the current “Belt and Road Initiative”. The city has established bilateral trade relations with 63 countries along the routes of this new Silk Road.
A major difference in healthcare between China and most of the Western countries is the number of patients. The Second Hospital Affiliated to Lanzhou University deals with a lot of patients, just like every major hospital in China. 50 percent of its patients are from the city, the other half flocks in from all over Gansu, including its large rural areas. The province is multi-ethnic. Besides the Han, who are the biggest ethnic group, Gansu hosts many ethnicities, including two other main groups: the Hui, and another Islamic culture, the Dongxiang. „We have doctors and radiologists with Hui and Dongxiang background who help us to communicate with patients,“ says radiology head Junlin Zhou. „We are a multi- ethnic department and ethnicity does not influence our diagnostic daily work in a bad way,“ he adds.
Not everybody in the hospital is a patient or medical personnel. Close relatives accompanying patients are a regular sight. Relatives support their family members in the scan room, some even stay during the scan. The radiology department at the Second Hospital Affiliated to Lanzhou University performs around 1000 CTs and X-rays per day, and does 200 MRI scans.
The students and residents in the X-ray reading room will be Gansu’s future radiology experts. The Second Hospital Affiliated to Lanzhou University is a quality control center for the whole province, where students get their training. Radiology department chair Junlin Zhou, who is also the current president of the Gansu Society of Radiology, focuses on improving the quality of radiology in all of Gansu. “Doctors all over the world are one kind of people, who are dedicated to life-long learning,“ he says. He believes that Chinese radiologists are catching up fast with their colleagues in Europe and the US: “As a Chinese radiologist, I have become more and more confident about my own work over time – we are definitely on the way to improve our level of research.“
The world’s most populous country is growing old. The much loathed one-child policy – which has formally ended in 2015 – is one reason, the considerably improved life expectancy another. In 2050, almost 500 million Chinese are expected to be over 65. The Second Hospital Affiliated to Lanzhou University is facing another problem: low diagnostic quality in the rural areas. The hospital uses digitalization to reach out: “Our hospital has its own website with educational sessions and we also have plenty of WeChat subscribers from the hospitals in our province – radiologists upload a lot of real cases,” says radiology department secretary Jianhong Zhao. The community is closely connected.
Peking Union Medical College Hospital (PUMCH), founded by the Rockefeller Foundation in the early 1900s, is probably the most renowned hospital in the People’s Republic of China. PUMCH is located in the heart of downtown Beijing, close to Tiananmen Square and the Forbidden City. Designated by Ministry of Health, PUMCH is now the national medical technical support center for diagnosis and treatment of severe and complicated diseases, making it the top referrer hospital in the country. 4000 staff, including 500 professors, work for PUMCH. Regarding radiology staff, it is also one of the most selective institutions in China, for medical doctors and for technologists.
Peking Union Medical College Hospital (PUMCH) has come a long way since the early 1900s. PUMC Hospital went through hard times during the war years. The hospital was nationalized by the People’s Republic of China in 1951. By the mid-1970s, it began its renaissance. “We have re-built the hospital during the last 30 years. We can rely on our culture to develop our department to the top in China,“ says Zhengyu Jin, director of the Imaging Department at PUMCH. Medicine has followed China’s huge financial and economic development. Radiology is no exception.
This hospital floor belongs to PUMCH’s older buildings. Walking around the block at PMUCH takes half an hour, if one does not got too slow. The campus, located in one of the finest and most highly-priced areas of the inner city, is constantly remodeled.
„The most important thing is to get the best people from the young generation for our hospital and our department,“ says PUMCH Imaging Department chair Zhengyu Jin. The selection process is tough. Testing the future resident’s clinical skills with the OSCE (composite objective structured clinical examination) circuit is part of it. The selection starts even earlier: PMUC, the medical college associated to PUMCH, is the number one faculty in China. Some years, no more than 20 students get accepted. Students are drawn from all over China, and they have to show the highest academic skills to get in. The China Medical Board, a division of the Rockefeller Foundation,established Peking Union Medical College in 1917.
] Publishing is part of a resident’s job description at PUMCH. The department has good international connections. This CT room is used for a study on dose for cardiac vessel depiction. While cardiac research is a focus of the department and part of the daily schedule, other research needs to be done during after-hours. A regular workday for residents includes eight to ten hours in the reading room. They get to see a wide variety of diseases in return. PUMCH as the top referrer hospital in China gets all the “zebras”, the rare diseases.
Zhengyu Jin is professor of radiology and the director of the Beijing Union Medical College Hospital (PUMCH) Imaging
Department. He has been representing Chinese radiology internationally for years. His department has become the number one radiology department in the Chinese best specialist reputation ranking list during his lead and has been number one for five years in a row. He is also the current president of the Chinese Society of Radiology. As CSR president, he intends to focus on education as well as internationalization: „I think the society needs to become more international – we need to go abroad to find more friends to let them know about China,“ he says.
The entrance hall of PUMCH’s outpatient section seems like light, white courtyard. In the morning, the registration is usually packed. The picture was taken in the early evening, so the majority of patients is already gone. It also serves as a sort of information retrieval center for patients: They can retrieve their examination film at printout machines in the hallway by using a code – either their insurance card, the hospital card or a special barcode. The machines even print two different film sizes. Not every hospital in Beijing is connected; patients need to bring their film to their outside referrer. Three radiologists, one each for CT, MRI, and X-ray, are on duty in the consultation room down the hallway. They answer any questions patients might have about their report.
Shantou, a port city in the very Southeast of China, is still often considered as „the tail of China“ – despite its five million inhabitants. The city is remote, far from the capital Beijing. Chinese people from other regions are unable to understand the special Shantou dialect. Yet there is another side to Shantou. It was one of the first four special economic zones in China. The city used to be poor, but nowadays contributes approximately one forth to the economy of the Guangdong province. Guangdong generates approximately 12% of China’s national economic output, with an economy of roughly the same size as Mexico. Guangdong is also the most populous province in China. The province capital Guangzhou is also known as „Canton“.
Shantou Center Hospital is the largest and most prestigious hospital in the city. It shares the fate of many similar hospitals: Patients know about its good reputation and rather make the effort to go the city than attend their community hospital close by. The results are also similar all over China: City hospitals are packed, community hospitals are empty. A government initiative introducing so-called Medical Unions is likely to help shift patients back to their primary healthcare centers. It sends experts from major city hospitals to community centers. Radiology experts from Shantou Center Hospital are currently in community hospitals, sharing their expertise with the staff and building trust with their patients.
] The Tropic of Cancer runs right through Nan’ao. The island off China’s Southeast Coast in the Chinese Sea looks like right out of a James-Bond movie. Nan’ao is about an hour drive to the city of Shantou, at least since the eleven-kilometer bridge connecting Nan‘ao to mainland has opened in 2015. Despite the good connection less patients go to Shantou for medical care. This is a result of the Medical Union concept, says Shantou Center Hospital’s radiology chair Xianheng Wu. He has sent one of his young and experienced colleagues to the community hospital on Nan’ao to take care of the radiology department. It works. “They did not trust their doctors, but they believe us, because we come from a big hospital with a very good reputation,” he says. “If small hospitals becoming useful, the patients will benefit.” The staff also seems to like the idea.
The reading and reporting session is a daily must at the radiology department at Shantou Center Hospital. It has not always been like this. “In the beginning, we did not have a good knowledge base, and our education system was poor,” says department chair Xianheng Wu. He started the educational morning reading at the very first day, when he took office in 2011. Initial reluctance soon changed to support. His predecessor still takes part in the meetings and the vivid discussions. Shantou Center Hospital has since become one of the very first hospitals selected by the government as standardized education centers. The hospital provides standardized fellowship and residence training. Theoretically, standardized education should be rolled out in all Chinese hospitals by 2020.
Kung Fu (or Gongfu) means the art of doing something well. This does not only refer to the Kung Fu tea ceremony, a ritual deeply rooted in the Shantou area and well-like by Daiying Lin, the radiology department’s Vice Chair at Shantou Center Hospital. It also refers to the 170 MRI scans the department reports per day. The team makes sure to explain the examination before the scan. As most of the patients are locals, medical professionals should be able to communicate in the regional dialect. “The spirit of our department is to serve as much as we can,” says Daiying Lin. Nonetheless, the patient throughput remains huge. Her hopes rest on Artificial Intelligence. “I would like artificial intelligence software to save me and my colleagues from repetitive work – we could do more research instead,” she says.
Shantou Center Hospital radiology professionals see around 600 patients in general radiology, up to 400 patients for CT, and somewhere around 150 MRI patients per day. While film printout machines are part of a useful process automatization in a huge hospital, communication cannot be replaced by machines, says Shantou Center Hospital’s radiology chair Xianheng Wu: “If you communicate with your patients, they will appreciate what you do and why you do it.” He believes this to be an antidote against the rather tense doctor-patient relationship, which is currently on the agenda. “In the news we hear about misdiagnoses and crowds gathering to beat or kill the doctors responsible for it,” explains Xianheng Wu. “We never experience cases like that here,” he says.
Patients are not exactly rushing into the radiology department at Nan’ao community hospital. Only around 70,000 people live on the island. The whole hospital has less than 200 outpatients per day. Yet, once they come, they find the technical equipment quality to be on a par with the big hospital in the city. An informatics upgrade will follow in 2018. If an image is too difficult to read, it can already be transferred to colleagues at the hospital homebase in Shantou right away. The government has invested the equivalent of 300 million Euro in the community hospital on Nan’ao island.
Zhongshan Hospital in Shanghai just celebrated its 80th anniversary in 2017. It is one of the leading hospitals in China and one of the biggest centers for liver, renal and even heart transplants. The hospital is affiliated to Fudan University, which belongs to the C9 League universities, the „ivy league“ of China.
Zhongshan Hospital is also historically special: It was the very first large hospital set-up and run by the Chinese people, which is why it was named after Sun Zhongshan (also known as Sun Yatsen). He played a major role in overrunning the Qing dynasty and was the first president and founding father of the Republic of China. Before Zhongshan Hospital, foreign institutions like the Rockefeller Foundation usually founded the big hospitals, and many regional hospitals were run by foreigners or charities.
The schedule of medical specialists and their consultation hours in the Main Hall of Zhongshan Hospital allows every outpatient to pick a specialist. These specialists are at least vice-professors. Professors are more expensive and waiting times are usually longer. Top specialists need to be paid directly. Radiologists also take part in this private patient service: The radiology chair sees private patients during two half days per week. A patient has to pay around 300 Renminbi (the Chinese currency), which equals about 45 Euro. Although China’s governmental healthcare system provides at least basic health insurance coverage for an estimated 95 percent of the population, healthcare is also a matter of money.
The insurance does not cover all the cost and out-of-pocket costs vary significantly. The government tries to intervene: The National Planning Guideline for the Healthcare Service System (2015–2020) aims at reducing patients’ out-of-pocket expenses, for example through the restrained use of medical devices.
Radiology professionals at Zhongshan Hospital are fast: The patient throughput time for one contrast-enhanced CT is somewhere between two and four minutes. This includes putting in an IV line, even while the gantry is moving. Plain CTs are quicker. “China has a very large population and we have to get accustomed to this situation, so the best chance for us is to have a very efficient workflow,“ says radiology department head Mengsu Zeng.
Zhongshan Hospital is mainly diagnostic, with a set-up similar to the Mayo Clinic in Rochester/MN, USA. It has an excellent reputation in China and even the APAC region, for cardiovascular and liver disease. About 50 percent of all patients come from Shanghai, the rest is drawn from adjacent provinces and abroad. The waiting rooms are usually packed. Although patients draw a waiting number, which is then announced, there is still a real person looking for them, because the waiting room is so busy that people often cannot hear the announcement. “It is crucial that patients are lined up correctly, because the throughput is awfully fast,” explains radiologist Rou Fan Sheng. Patients are told to not come with clothes they need to undress. The superfast throughput results in less privacy. Doors may stay open. Privacy does not matter that much. “Chinese are used to that kind of exposure to other people – bur we try to give them more privacy,” says Rou Fan Sheng.
100 radiology technologists work for Zhongshan Hospital in Shanghai, 50 seniors and 50 juniors. Chief technologist Caizhong Chen steers his staff digitally. He distributes schedules and does a lot of the communication with his own smart phone. The adoption of mobile communication is visible in every aspect of life in China, from messaging to mobile payment services, which are also widely available in hospitals. The most common platform is WeChat, which is also called China’s „App For Everything“. Knowledge transfer among the technologists at Zhongshan Hospital is only partly digital. A senior and a junior technologist work together at every machine. „The young people learn a lot from the senior technologist,“ says Caizhong Chen. The team also meets for a two-hour lecture every two weeks.
] Zhongshan Hospital has 12 CT units and 7 MRI units. The radiology team sees approximately 1000 CT and 500 MRI patients per day. „We work from 8 a.m. until 8 or 10 p.m.,” says radiology department head Mengsu Zeng. “We once were an auxiliary department, but now clinicians from our 44 faculties depend on us,” he adds. The radiologists do their work in more than ten reading rooms. There is usually a senior radiologist in every reading room, together with three to five juniors. Medical students and radiologists in training form outside hospitals usually join the team. “It happens quite often that we do not have enough computers for everybody,” says radiologist Rou Fan Sheng.
The First Affiliated Hospital to Zhengzhou University is the largest hospital in China, which means it might well be the largest hospital in the world. The 21-story building is the outpatient ward on the main campus. The hospital has three campuses throughout the city, with a total of 11,085 beds, about 8,000 are on the main campus. The radiology team sees 20,000 patients each day. The term “Affiliated” to a university means that the institution is a university hospital.
It is Saturday afternoon and the hospital has switched to its rather empty weekend mode. It looks quite different during workdays: The plaza in front of the outpatient building is usually full of people. They wait outside for half an hour just to get into the main hall. The main hall looks more like an airport than a hospital entrance: Stewardess-look-alikes in dark pink uniforms with heart shaped nametags at the information desk guide patients to the right department. What looks like check-in machines, are either really check-in machines, or ATMs, or schedule appointments, or print out films. CT and MR images need to be printed out, because referrers are usually not digitally connected. Patients need to bring the images.
The radiology department of the First Affiliated Hospital to Zhengzhou University is located in the basement of the outpatient building. Patient numbers have grown enormously during the last decade, not only in radiology. This is mainly due to the “no patient will be turned away” policy of the hospital’s president Kan Chuen Chang. Patients value this attitude. It has led the hospital to grow from 1,000 beds in 2008 to 11,085 beds in 2017, about 8,000 on the main campus. And another fact adds to the high patient number: Zhengzhou is the provincial capital Henan, one of the most populous provinces in China.
The hospital’s vice president and CT department chair Jianbo Gao considers enough high-tech equipment one of the most important things for radiology. The First Affiliated Hospital to Zhengzhou University has currently 300 ultrasound machines, 34 X-ray-based scanners, including mammographs, 23 DSA machines, 20 CT scanners, 17 MRI scanners, and 6 PET-CTs with the according nuclear medicine equipment.
Jianbo Gao comes to the hospital at seven in the morning and leaves at midnight. “If I have a business meeting in between, I will still come back and work here,” he says. Besides being the head of the CT department (MRI is a different department), he also serves as the hospital’s vice president. He sees three main challenge for its near future: keeping the status as the biggest hospital, keeping up innovation, and continuing to get stronger. „Remaining number one is our biggest challenge,“ he says. He wants to establish radiology as one of the most advanced disciplines at the hospital and tries to further strengthen the hospital’s international standing.
The First Affiliated Hospital to Zhengzhou University will soon remodel its centerpiece. What is now the hospital’s parking lot is about to become a multidisciplinary research center. The new building will have about 140,000 square meters. Radiology research will be part of it. The radiology department already only purchases world-class equipment, a policy that already has effects on the hospital’s international visibility. “We do a lot of research with these new techniques, which helps our radiologists to get their papers published at RSNA or ECR, “ says CT department head Jianbo Gao. For the last couple of years, an average of around ten radiology employees has attended RSNA with a lecture or a poster. The hospital strongly encourages these special research accomplishments. Publications in international journals count as well: A researcher gets 10,000 Renminbi for every Impact Factor; if the paper is above 5, the amount is doubled. Despite the bright future of research in Zhengzhou, the picture also shows a darker side of the city: Zhengzhou has some of the worst air quality in China.
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