By John Carruthers, assistant editor, December 02, 2013
As the largest country in the world by population, China faces the logistical issue of providing health care to over 1.3 billion citizens. A total of 18,000 dermatologists serve the needs of that population, mostly through hospital systems. Specialists are highly encouraged to publish research and engage with international colleagues. As the health system continues to modernize in reaction to the need for services, dermatologists have gradually become better organized and more involved in pushing the frontiers of the specialty.
An evolving care system
Since the 1949 governmental initiative to improve overall health conditions in the population, the Chinese health system has undergone a number of sea changes. A 2008 series of articles in the Lancet divided the evolution of health care in modern China into five phases:
Following the establishment of the People’s Republic of China, the government took over the patchwork health care system and devised a centrally-managed three-tier care delivery system. New schools for medicine and nursing were established.
The Cultural Revolution closed universities and medical schools for a five-year period. The “barefoot doctor” program was introduced and trained tens of thousands of rural citizens in basic medicine to provide care to the underserved.
Rapid economic development led to further systemic reforms. Responsibility for health care management was decentralized to the provinces, which increased the disparities between urban and rural care. Financing for health services began to privatize. The barefoot doctors program was abolished in 1981 as the commune system ended.
The government attempted to control quickly rising costs, as well as address the health costs of rapid economic development, including obesity, workplace injuries, and health issues caused by pollution. Fledgling private providers and health care facilities began to operate and expand to meet the demands of the new, mostly urban middle class.
Following the highly public fallout from the SARS epidemic, the health care system was fundamentally reformed, with more resources allocated to public health and a partial resumption of centrally-managed health care services. (The system had been portrayed in international media during the epidemic as poorly coordinated and inequitable.) A new cooperative medical system was created for the rural poor, with a similar program put in place for the poor and underserved in urban areas. Under the new health system, the annual cost of medical care under these programs is 50 yuan (about $8) per person. Of that, 40 yuan is paid by the central and provincial governments, and 10 yuan is charged to individual citizens. (China’s annual income in 2012 was 13,000 yuan, or about $2,100, with lower incomes seen in rural areas.)
The many and ambitious changes in approach over the years have required the allocation of considerable resources. Much of the funding for these public health initiatives in both China and its special administrative region of Hong Kong, according to private practice dermatologist Henry Lee Chan, MD, who practices in Hong Kong, comes from reallocated taxes on individuals.
“While Hong Kong has a very low tax system — 15 percent personal tax as a flat rate — we have a very good health care system with the public services providing care to the underprivileged,” he said. “The system serves as a safety net and is important to the community.”
Former Academy president Stephen P. Stone, MD, who traveled to China on three separate multi-city speaking tours, said that the recent efforts at modernization have resulted in facilities and academics that compare very favorably with Western medicine.
“The first time I traveled to China, I was initially surprised at just how up to date the major hospitals were,” Dr. Stone said. “It was quite clear that the Chinese are keeping up with Western medicine today, though there is still some investigation of and definitely a market for traditional Chinese medicine.”
Roots of the specialty, current organizations
China has one of the oldest traditions of medicine in the world, and likewise, dermatologic conditions have been studied and treated for centuries by both traditional and contemporary medical practitioners. According to a 1982 piece in the Archives of Dermatological Research, excavated remains of the Shang Dynasty included words such as “chieh” (scabies) and “pi” (head lesion) carved onto turtle bones. During the Chow dynasty (1066-771 BCE) physicians who dealt with cutaneous disease were classified as surgeons under the Chow Rituals, which distinguished four classes of doctors. In 610 CE, Tsao Yuan-Fang published a work titled Etiology and Pathogenesis of Diseases, which included descriptions of over 60 skin diseases.
Medical dermatology was introduced (as dermatovenereology) to China via American and European missionary physicians in the middle of the 19th century. A number of hospitals were established to bring Western-style medicine to the country.
The following century, in 1931, dermatologists Chester N. Frasier, MD, and Ch’uan-K’uei Hu, MD, reported hypovitaminosis A for the first time at Peking Union Hospital (Arch Intern Med 48:507–14). Soon after, in 1937, the Chinese Society of Dermatology was founded as a sub-section of the Chinese Medical Society.
Today dermatology residency in China is a three-year process, undertaken following three years of general medical training. Following completion of residency, students are able to take their medical boards, administered by the Ministry of Health.
“The dermatology board exam is given as a step 1 and step 2 by each university, as they don’t have any equivalent to the American Board of Dermatology, for example,” said American Academy of Dermatology President Dirk M. Elston, MD, who recently returned from a trip to China. “Laser and dermatopathology certificates are delegated to provincial governments, much like state medical licenses in the U.S.” After licensure, Dr. Elston said, promotion and career advancement is largely based on published research in Western journals.
Indeed, as a result of recent health system reforms, grants are now more widely available for dermatologic research. More than 300 papers from Chinese dermatologists have appeared on the Science Citation Index over the previous five years (J Invest Dermatol 129: 1049-1050).
“Many of the dermatologists in China do research fellowships in the U.S. before going to China and entering practice. Being published in a Western journal in English is certainly an aid to one’s academic career,” Dr. Stone said.
Interest in dermatology among Chinese physicians continues to advance. In 2007, the Chinese Society of Dermatology voted to increase the frequency of its scientific meeting from bi-annual to annual. The society also partners with the Japanese Dermatological Association to host joint meetings. In 1998, 2004, and 2007, the country hosted international meetings for the Asian Congress of Dermatology, the International Congress of Dermatology, and the International Society of Cosmetic Dermatology. In 2013, the 9th Asian Dermatological Congress was held in Hong Kong.
In addition to the Chinese Society of Dermatology, the Chinese Dermatologic Association began in 2008 as a small trade association and now has a small scientific meeting each year.
In contrast to the U.S., almost all dermatology practiced in China is hospital-based.
"The responses that I heard during my visit to China all alluded to the fact that the population trusts care in a hospital setting and doesn’t view private practices as equivalent,” Dr. Elston said. “The major drawback to the system is that patients come in without appointments and push the demand so high that the dermatologists have less time with the patient than they would like. It’s about twice the number of patients that a dermatologist in the U.S. would consider a comfortable volume.”
To combat the effects of the overcrowding that can occur, Dr. Chan said, his practice sends all its staff members to a hotel service training course, as do some other practices. The cross-training, he said, helps them improve their communication skills and ability to relate to patients.
On speaking with the dermatologists in China over the course of his visits, Dr. Stone said that, like Dr. Elston, he was struck at the lower proportion of solo practitioners in the country compared to the U.S.
“The impression that I had in speaking with dermatologists in China was that the specialty is more of an academic specialty in the way of France and Great Britain, where many of the researchers are professors, are hospital-based, and are teaching,” he said.
The major conditions treated by dermatologists in China are eczema, psoriasis, and connective tissue disease, according to Dr. Elston. In addition, he said, a number of therapies not approved in the U.S. are offered at clinics geared toward traditional Chinese medicine.
Patients in China and Hong Kong, according to Dr. Chan, display different sensitivities to certain conditions.
"Here, patients are more prone to develop complications after laser procedures,” he said. “Especially post-inflammatory hyperpigmentation.”
In addition, Dr. Chan said he sees pigmentary conditions with a greater frequency than Western dermatologists, including nevus of Ota, lentigines, and Hori’s nevus. And he uses different treatment modalities than his American colleagues.
"Quite recently, I wanted to refer a patient with extensive alopecia areata, which was well-controlled with diphenylcyclopropenone,” Dr. Chan said. “I reached out to colleagues in Boston and found that nobody there performed such treatments.”
During his visits, Dr. Stone said, it was clear the dermatologists in China were able to utilize many drug therapies not yet approved in the U.S.
“Many of the medications that had not yet been approved in the U.S. but had been approved in Europe were available in very similar forms. International pharmaceutical companies are certainly present. During one of the sessions, the organizers played an animated cartoon commercial for a topical antibiotic between the talks,” Dr. Stone said. “This was in the urban areas. Some of the more rural areas we remote-broadcasted to did not have access to imiquimod and some of those types of newer drugs, but they were certainly available in the cities.”
China at a glance