Chinese medicine clinical rotation Part IV of IV

The #1 suggestion I can make about any TCM program in China is to learn Mandarin!!!! Without some level of language you will be at the mercy of your translators. They will work their tail off for you but realistically in a seven to eight hour clinic shift no one can stay on point the entire time. And even with university taught translators, Chinese and English are not 1:1 languages. I’ve been amazed at how often the Chinese dictionaries have the most bizarre translations for simple terms. Scurf? Oh, that’s dandruff. Swirls? Vertigo. We spend a lot of time during clinic sessions looking up words that just don’t quite translate, so they’re learning on the job just as much as you are sometimes. There are clinic advisors and doctors who speak English, but they are there to treat patients, not translate the consult word for word. So out of a 5-15 minute intake you may only get the main symptoms, and you will miss some important details. Having the vocabulary to at least understand what questions are being asked will keep you and your translator on track, and if there’s a response you don’t understand you can follow up later. “Laoshi, the 40 year female with thyroid cancer spoke at length about her digestion, and I didn’t get it all. Can you explain a bit?” 

Most of the doctors really enjoy teaching, so they will bring up important points to you and your translator - interesting pulses, or tongues, and symptoms or specific patterns. As my concentration is herbalism, they especially like to bring up esoteric text or point out how few herbal text have been translated to English. While the TCM education is the foundation here, every doctor I encountered had their specialty - Fire School, Pi Wei Lun, Shang Han Lun, etc. Also, I’m blown away by the general level of education with my peers. If I haven’t heard of a formula they all immediately chime in the source - Jin Gui Yao Lue for example, or some historical figure. I’m completely inspired by their scholarship!!

So, where to start learning Chinese? I suggest everything you can get your hands on :) Rosetta Stone for pronunciation and character recognition, Pimsleur for pronunciation and hearing everyday phrases, the Wiseman Chinese medicine vocabulary books, and every single podcast, and online video you can handle. At the very least, look at the Asking Songs, and translate them yourself. I’m working on a translation, and will post it when I’m finished. I’m cross referencing my translation with clinic notes so that it is accurate with current Mandarin vocabulary and TCM terms.

There’s also a very serious course with Nicolaas Herman Oving, but it’s more geared towards reading Chinese medicine text. I have no doubt it would also be helpful:

http://ovingchinesemedicine.com/cat-1/online-courses-in-chinese-medical-chinese/

As a sidenote, Duolingo just released their Mandarin Chinese app so I’ll jump into that as soon as I get home!!

TCM clinics in China are like nothing you’ve ever experienced. First, in my experience most doctors either prescribe herbs or perform acupuncture and moxa. Rarely do they do everything in one clinic the way we do in the states. They may refer out to another doctor, or maybe an herbalist will drop some needles in a patient during a consult for expediency, but generally its herbs or needles/moxa. Secondly, clinics in China are crazy. The patient is almost never alone, the room is filled with unrelated people, sometimes as many as 10-12. There’s yelling, running commentary, phone calls, texting, video games, constant interruption of the doctor, and the ever present line-cutting. HIPPA? Hah!!! Average patient load in a 3-4 hour session is between 15 to 40, but one doctor that I work with sees 100 patients in an 8 hour shift. There have been several fights in clinic waiting rooms as people try to jump the line or visit a doctor without an appointment. In many cases one person makes an appointment, but brings the records for a family member and expects the doctor to also write an herbal prescription for them as well. They generally have pics of the absent family members tongue. Also, acupuncture clinics are a lot like community clinics in America, but a lot louder. The patients are all in one room, and usually know each other. They banter and talk most of the time. It’s a like a weekly bridge club. “How’s your hemorrhoids, how’s your prolapsed anus, is your husband alive or did the cancer get him”, you know all the regular chi-chat.

If the doctor is popular, there are probably anywhere from 4-8 students observing. As a foreigner you sit, keep quiet, and stay out of the way. The university even sends out a memo before you arrive about clinic etiquette. At some point people will engage with you, but generally it’s expected you will not interrupt. The doctor will ask, when they are ready, if you have any questions, and if they feel you’re up to it, see if you have any answers when quizzing their own students. No one brings a laptop, all student notes are handwritten. Once in a while an iPad might come out to look something up that needs a larger screen then the phone, but its rare. As a foreigner in a Chinese medicine clinic you will draw a certain level of attention anyway. This where a little language skill can bring you some peace, and some respect. 

Clinic dress codes are very casual. You will be expected to wear a white coat, but underneath you can be comfortable. Most of the other students wear jeans and sneakers, teachers and doctors usually a button down shirt. I keep it business casual, I always wear black pants and a button down, and never sneakers. 

I would say the hardest thing to deal with is loneliness. The translators and teachers are great, but at the end of the day they want to get back to their lives. Which leaves you alone in a hotel or apartment with your loved ones in a different timezone and on a completely different schedule. I’m super active and walk the entire city, but there are many lonely moments, and social media can actually be of help here. If you’ve got friends around the world, someone is awake with you. Blogging, posting pictures on Instagram, FaceTime, all these things help you stay connected to your world. Interestingly, I see quite a few Americans and Europeans here, but rarely does anyone engage. It’s almost as if people pretend not to see each other as speaking to a non-Chinese person will ruin their “authentic” experience.

Its important to remember that China is not one experience, like the language and Chinese medicine, its a massive melting pot of ideas and cultures all under one umbrella. Every time I see someone say that “China is this way…” or “this is what the Chinese do…” I think hmm, maybe they only visited one place. Every city, every family, every clinic and teacher has their own take on things. There’s even a saying, if you’ve visited Beijing, Hong Kong or Shanghai you still haven’t seen China. It’s completely true. In addition, change is on warp speed here. Something that was happening 2 years ago will be gone, and the whole country will have shifted. That being said they are really into Kenny G, remakes of 80’s classics, and torn jeans right now…

In the end, this is completely worth it. I’ve seen around 1,000 patients in 5 weeks, my Mandarin has improved immensely, and I’m laying the groundwork for future trips and research projects. I absolutely recommend DAOM programs to aspiring TCM students, and wholeheartedly suggest that TCM practitioners visit China in whatever capacity they can. You have to be ready for change, and the unexpected, but it can be absolutely life changing. 

Chinese medicine clinical rotation Part III of IV

Where to stay? 

For the Zhejiang program the clinics are too far from the main campus to stay in a dorm. I searched and searched, and looked at many hotels, but in the end I went with Airbnb. It was cheaper and offered nicer accommodations with a kitchen and washer. The average hotel that is worth staying at in Hangzhou is about $60 per night, anything less and you’re gambling with your health. There are some $30-$40/night places, but I wouldn’t stay there longterm. Even with Airbnb it can be rough making arrangements. In my first attempt I asked the host if they could help me register (more about that in a minute), and they never replied, the second request, I simply asked if they will host a foreigner, and when they said I “yes” I asked about registration - silence. The third attempt I just booked the dates, and figured I would worry about registering when I got here. So what is this registration all about? When you check-in at a Chinese hotel they take a copy of your passport and load it into a system that basically lets the government know where you are. Of course, with Airbnb that step is eliminated. Technically, your host should accompany you to the local police bureau to help you register so you are in the system. For the most part, no one does this for short stays. I asked everyone I could think of, and just about all of them said don’t worry about it, this includes my in-country advisors. If you’re staying for more than a few months, it might be worth it. But no one is scouring the database to see who hasn’t registered, and really the only time if would come up is if you get trouble or an accident. So keep your sh*t together, and don’t get in trouble :)

Chinese apartments run the gamut of ultra modern clean, to scary, built before running water. The outside may look old and dirty, but the inside could be updated and clean. Apartment showers are generally in the same room as the toilet with a drain in the floor. Consider yourself lucky if you find a bathroom with a separate shower stall. Hotels are different, they’ve mostly been upgraded at this point. For the most part, in major cities western toilets are now the norm. You will still encounter squat toilets, but its pretty rare. For some reason, they cannot get the smell thing down. I have literally walked into a pubic bathroom right after the cleaning crew finished and it still smelled awful. I used to think it was the lack of water in squat toilets, but now with western toilets the smell is still there. Also, there may be bugs in your apartment, it’s just a fact of life here. Apparently, sealing windows, vents, even caulking bathroom tiles is not very consistent. It’s not awful, but they’ll be there. I had an 8 inch millipede on my towel one night. Scared the crap out of me… The most important point about living arrangements is making sure you are close to your clinics. For the Five Branches/Zhejiang program I would suggest being close to Westlake, somewhere between Hefang Street and Qingchun Road. That should keep you within a 25 minute walk of all the clinics. Getting to the main campus is a long bus ride, but the new subway line should be open by the end of 2017, and it goes right to campus!!

Costs are kind of strange. Food is ridiculously cheap. I spend on average 18RMB to 28RMB for a meal, about $3 - $5. My average tea costs 32RMB, about $6.50. So yes, I have spent more money on tea than food. There are the cheap tchotchkes to buy, but then nicer items are actually more expensive than Europe or the USA. 

Note, there are scholarships for foreign students and I would encourage everyone to badger their advisors about them. I received one after my arrival even after being told I was not eligible from home.

Packing is easy, don’t freakout, most of your general toiletry items and foods are available here. Razors, soap, shampoo - you don’t need to bring 2 months worth. Clothing too, the malls have all the usual stores from around the world like H&M. I would recommend a good pair of soft soled clinic shoes, and a general walk-around pair of shoes. Honestly, I’m throwing away my walking shoes after this trip. It was very rainy when I got here, and they’re just generally gross at this point. I completely over packed for this first trip...

A few people have asked me about vaccinations. That’s tricky of course with all the new information we have at hand, and all of the controversy. I was vaccinated as a child in the 70’s and had boosters for tetanus before my first trips to Sri Lanka and China in 2005/2006. I also got the Hep A/Hep B vaccine then, and that’s something I would suggest for China. Its estimated that greater than 8% of the population of China has Hep B, whereas in the USA its less than 2%. One of my supervisors believes that Hep B infection rates are closer to 20%. I’ve also seen mumps here, that was scary to see in person. And I would say the majority of the population has oral herpes, cold sores, so you want to be careful about sharing drinks, food dishes, chop sticks, etc., especially if you have not had a cold sore, and are not sure if you carry the virus.

Herbs and Medications

I usually take some version of Yu Ping Feng San or Dragon Herbs Supreme Protector starting about 2 weeks before I travel, and about one week into the trip. I’ll then hit Wu Ling San and Supreme Protector again when I get home to help with the jet lag and immune system lag. You can get just about any medicine here, but if you like a specific brand, even Chinese formulas, bring them with you. You may not find exactly what you’re looking for. Like many developing countries you can buy antibiotics and other medications right over the counter...

Almost at the end...

Chinese medicine clinical rotation Part II of IV

Bike parking lot in Zhejiang University

Getting Around

You will put your life in god’s hands every single time you cross the street. There are people on bikes, scooters, and every other form of motor vehicle seemingly in a rush, but not really traveling that fast. All of the stereotypes about Chinese drivers are true, the absolute worst. I’ve had people look me right in the eye, acknowledge me, and then hit the gas pedal in a panic. I was actually hit in a parking lot the other day while looking the driver right in the eyes, we were smiling at each other and I was mouthing “you see me right?” She just waved and drove off as I limped to the bus. Bike riders will fall over, or hit random people, scooters on the sidewalk, driving down the wrong side of the road or the wrong way on a one-way street, its pure chaos. And the honking never stops!!! If you can get into the flow you can actually move quickly through the city, but seriously its crazy. There is zero traffic enforcement here, really you never see the police. Most security is performed by building or apartment complex security teams, and they can be kind of bully-ish to the locals.

The subway is very easy to use with English and Chinese announcements. One warning, your map apps may have English street names, but the automated subway machine will not, so best to look up the street name in both Chinese and English before you try to buy your tokens. Also, the Apple map app often has difficulty finding an exact address. Best to enter the street name only with the city, and then narrow down your street address by picking a location close. On several occasions the app tried to lead me across town or to a different city with the street number in the search. There must be errors in the translation algorithm.

The bus is equally as easy, and your map apps should show you available routes and times...

There is an Uber type called DiDi, but I ran into difficulty when it wanted to use my as yet unlinked WeChat or Alipay app for payment so I never got to try it. 

Eating...

                                  Beef Noodle Soup

Food, this is not your Americanized Chinese food. It’s better!! Much less sugar, and lighter sauces, but there is MSG, in some places its practically a table condiment. Again, I’ve never (knock on wood) had food poisoning here, but I’m relatively careful. I eat at restaurants with a high turnover, and really give a place the once over before I try it. One piece of advice, don't ever look in the kitchen. Also, a lot of restaurants reuse plastic and sometimes wood chopsticks, if the freaks you out, bring or buy your own...

Hangzhou in particular has quite a few high end places to eat, and seems to be undergoing a bit of a foodie moment with very new, clean, western looking restaurants opening. Of course, if you’re desperate, there is McDonalds, KFC, Pizza Hut, Dairy Queen, Burger King and Starbucks. Ahh Starbucks, whatever your feelings are about Starbucks at home, it will probably become your place of respite in China. Guaranteed internet, familiar drinks and food, relatively clean bathrooms, and plenty of locations. In Hangzhou you could practically walk from location to location before finishing your tea. Some locations are mostly empty, and others a zoo. At my local, people will sit there all day on a Saturday, sleeping and watching videos. The internet there is faster than what most people have at home too. 

Internet...

Which brings me to the internet. Yes, the great firewall will shut you down. If you’re constantly plugged in at home you will be tortured here. You must have a VPN app on all of your devices. The VPN basically lets you jump the wall by sending small encrypted packets to servers around the world allowing you access to google, gmail, Facebook, Instagram, etc. The issue of course is that the government doesn’t like VPN’s so they’re constantly updating the firewall. It’s a cat and mouse game for sure. I have 2 paid VPN’s (Expressnet, and Vyper) and a few free ones, and sometimes nothing works. Internet can go from blazing fast to an early 1990’s crawl, to instant stoppage. If you’ve got podcasts and TV shows you follow I would suggest pre-loading before you come to China. 

Zhong's Huge Bookstore, Hangzhou

Communication

With regard to phones, I always have 2 phones in China. My current iPhone with international service turned on, and most of the data roaming shutoff (actually I keep messenger and map data on, everything else is off), and I have a Chinese cell. For the second phone, use whatever phone you can find that is China compatible (usually quad band), and order a SIM card online. You can get them in vending machines at the airport when you land, but I find it easier on my brain to have this little detail sorted before I land. Its just one less thing to think about after 14 hours of travel, customs, and worrying about getting to your hotel or apartment for the first time. It’s really nice to have a local number, your Chinese peers will appreciate it, and the calls home are cheaper. Also, many restaurants and cafes will require a local phone number for you to log into their wifi. It’s a security feature at most foreign owned businesses like Starbucks. That being said, the entire country communicates with WeChat (Weixin). Set it up at home, and be prepared for the onslaught of messages. It’s like Facebook, Instagram, and a messenger app all in one. In some local places, including the clinics, you can only sign into their wifi with WeChat. 

There’s also a huge push to use e-payments here. WeChat and Alipay are the dominant ones. I wasn’t able to make them work from China because you need a Chinese bank account which foreigners cannot get. I’m hoping when I get home I can open an account at ICBC in the states and enable the payment apps. Also, Union Pay has replaced Visa and MasterCard at most places, and once again only Chinese banks issue Union Pay cards. I hear American Express and Discover are Union Pay compatible, and I’ll investigate those as well when I’m stateside. Either way I will post an update…


11/21/17 P.S. Just as I was leaving China I saw a billboard for a Unionpay app, so I'll also investigate that one too.

To be continued...

Chinese medicine clinical rotation Part I of IV

When I decided to apply to a Chinese medicine degree program in China I started searching around the internet but there wasn’t a lot of information out there, just some poorly translated Chinese university sites, and a few blog posts about shorter clinic trips. Off course there are lots of expat tidbits from people who teach foreign language in China or that have other gigs, but no one really described the experience of working in Chinese clinics with a university long-term, or even how to begin. I had visited Nanjing TCM University years ago with the idea of completing my masters studies there, but it was kind of an administrative nightmare. For the doctoral degree I was lucky in that Five Branches University offers a dual degree program and guides you through the entire process with relative ease. Since I was accepted into the program last spring I’ve received a lot of questions about doctoral programs, traveling in China, observing in Chinese clinics, and how it all works. I broke this out into 4 parts so it might be a little more digestible :)

To my knowledge, only Five Branches offers this level of integration as a dual degree program. Other schools have externships and shorter clinic trips, but Five Branches has a relationship with 5 different Chinese universities that not only offer an externship, but also fully accredited degree programs. With the timing of my program and degree requirements, Zhejiang University was my school of choice.

Application and acceptance is relatively straight forward on the American side. But as with most Chinese administrations, communication is difficult, and getting the answers you need may take more than a few emails, even if your American admin is handling the initial process. As mentioned in my last post, I arrived in Hangzhou with little more than an acceptance letter, visa, and contact emails. I knew nothing of my schedule or even what I might be doing here. But once I landed, I was thrown into the fire. Arrived on a Thursday night, met with my advisor on Friday, and on Saturday I saw over 100 patients during grand rounds…

If you haven’t traveled to China before, I would highly suggest a tourist oriented trip before coming here for a medicine program. It can be a lot to take in. Get used to the people, the food, the weather, in short get grounded. Once you arrive for your internship you will be running most days.

Here are some random thoughts I’ve had over the weeks, hopefully you may find it useful...

The view from the trail to Baopu Daoist Temple

Pollution?

Pollution in China gets a lot of press around the world, and especially in the USA, but I honestly have to say apart from Beijing I haven’t experienced debilitating pollution in the 11 years I’ve been traveling around China. I know its here, I’ve had some difficult days in Beijing (bronchial infection is 2008), but I’m more worried about second hand cigarette smoke than I am about pollution. The air in Hangzhou has been fine, and I never think twice about it. Even in Nanjing, where I’ve heard pollution can be bad, I’ve never experienced it in at least 6 different trips there. On one spring trip last year the blossoms on the trees were torture, but not the pollution. If you can handle the worst of Los Angeles I think you’ll be fine in most of China. 

Water

No one drinks from the tap in China. Boiled and bottled water everywhere. So for the environmentally conscious it can be difficult, you’re just going to use a lot of plastic. There are recycling bins on the streets though. I have one large bottle in my kitchen for tea/cooking and brushing my teeth, and usually carry another around with me. I’ve never been sick in China, but why risk it?

Cleanliness out on the street is, interesting. Again if you haven’t been to China be prepared. All bodily functions are on display, but probably the hardest to get used to is hacking and spitting. Starts early in the morning (its actually my alarm clock), and continues throughout the day. I have seen the most elegantly dressed Chinese woman, standing on a corner with friends on their way out for the night, fly an air-hanky right into the street. But it’s usually men that lead the hack-pack.

And did I mention the smoking? Out of control, worse than any country I’ve been to. Finding a breath of fresh air can actually be difficult. Of course there is zero awareness, people light up in hospital waiting rooms, and restaurants right next to a no-smoking sign. I’ve seen chef’s light up in a restaurant cooking my food…

Be sure to click forward to part II