Without noticing it, I crossed a threshold. Or perhaps I walked right into a mirror without realizing it? Do I look different? Do I have bruises?

It's been ten years since I started blogging, first here, then here. Now I'm blogging at the book site too, in parallel.

As the Hebrew poet Y.L. Gordon asked, "Le-mi ani ameil?" Who am I laboring for? As a doctor, the answer is clear: I have a patient I am trying to help. As a researcher, there is a community of peers I am trying to satisfy (and a hoped-for public that the research benefits).

For the writer, whether creative or expository, the answer is less clear. Sometimes there is no other reader, and that's okay. Sometimes the blog is a diary. Thoughts sound different when let out in the open air than when kept inside the head. I can be a writer and reader at the same time. This might help me develop thoughts which are useful to others, or can be expressed in longer form with greater attention to satisfying a certain public.

Talking To Your Doctor has been out for six months, and there is still a steady trickle of purchases. I am grateful for that. But it's time to move on to the next book. That means less frequent posts - perhaps a decrease here and there in the level of polish and rationality. Maybe some more experimentation as I try and flesh out some thoughts.

Happy New Year to all, and I look forward to providing more details about this coming project as it finds form.

I had a great interview with Gail Zahtz last week. She really gets it all: the importance of encouraging relationships between patients and their primary care providers; the inequality pervading our current system; and the tensions between academic and community medicine. The interview was two hours by the clock but it went very fast. Have a listen.

A country is like a person. Initial impressions matter, but if you really want to know them, you have to spend more time.

The Chinese health care system has many problems in common with the US: inequalities, lack of access, and widespread corruption due to the profit motives of pharmaceutical companies. Both systems are afflicted by overuse of services without clear health improvement. In the US, doctors get paid more if they order more tests; and in China, doctors' salaries often do not meet their cost of living, while they are allowed to make direct profits on pharmaceuticals and tests: the resulting incentive is clear.

But generalizations don't go very far in the hugeness of China. Beijing has 18 million residents or so, but Shanghai is China's largest city, and its health care system is significantly different from Beijing's, thanks to the reforming efforts of its vice-mayor who is implementing the Chinese equivalent of accountable care organizations, reforming residency education, promoting family practitioners as the integrators and gatekeepers for health services, and pushing through vertical and horizontal EMR integration. (The article from which I gleaned this information is based on an interview with this very vice-mayor, so the successes should probably be taken with a grain of salt.)

In the cities, where two-thirds of Chinese now live, public hospitals deliver the vast majority of health care services (accounting for 65% of health care costs nationally), but do so inefficiently and ineffectively, and are thus a chief target of governmental efforts at reform.

Out in the villages, where significant numbers of Chinese still live, the situation is very different from these big cities: access to care is dismal and quality a big question mark.

For now, I am grateful to have come to China not just as a tourist, but to learn something, share some of my knowledge with my hosts at PUMCH, and hopefully to start up some substantive collaboration.

Thanks to Dr. Jun Zeng and the entire GIM division at PUMCH. Thanks also to Junya Zhu of the Johns Hopkins School of Public Health for a crash course in the Chinese health system.

On this third full day as a guest in Beijing of the General Internal Medicine department at Peking Union Medical College Hospital, or PUMCH, I had an enlightening chat with the medical student I have mentioned in previous posts.

We were walking towards an outpatient GIM clinic down a corridor choked with people; these clinics are overbooked because of PUMCH's reputation (I'm not sure if there is a doctor shortage in China generally). I asked how much it cost to see a doctor in this clinic. "7 yuan," he said. I kept going. How much does a CT cost? An MRI? A knee replacement? He gave specific costs without hesitation. "How much does a CT cost in the US?" he asked.

I laughed. We both knew the question is ridiculous. Transparency in cost and quality is a dream for the US system given the extent of variation in health care use and that hospitals can charge whatever they damn well please.

It was appropriate, then, that I gave a talk today at PUMCH on public reporting: that is,  information provided by various entities on cost and quality in the US, and whether this information actually changes decision making, patient satisfaction, or outcomes. An article we published on the topic is here.

The audience included not just doctors, residents, and medical students, but members of the medical affairs staff and those concerned with hospital quality at PUMCH. It appears there is not much research literature addressing how patients pick their doctors in China. Given the completely out-of-pocket nature of much of Chinese health care, however, it could be that greater price and quality transparency is possible in the Chinese system than in the American.  To take one example, on-line doctor ratings in China appear to be widely used and, as I was told at any rate, influential.

The high point of today, however, was observing in the outpatient clinic of Dr. Jun Zeng, the head of GIM at PUMCH and, in addition to being an internist, a rheumatologist. From a diagnostic and treatment perspective, I saw that she used corticosteroids in many cases where her American counterparts in rheumatology would use the increasingly popular, and expensive, TNF inhibitors. I asked her about this and she said proudly, "I've been practing for 20 years and know how to use these mdications in a stepwise fashion - steroids work in many cases, and TNF inihibitors are not always needed."

I loved to see how she sat a table face to face with a patient, writing in a notebook while her junior colleagues provided prescriptions to the patient she had just seen. "What's the matter?" she started off a visit, and another - "What can I do for you?" Great openings. I couldn't understand all the Chinese, but I could see someone who was doing her utmost to provide patient-centered care given the limitations of her system - which, come to think of it, I need to ask them explicitly about: what frustrates them about Chinese medicine in the same way that my frustrations typify American medicine?

My second day started with a question from the medical student, named Shine, who has been coordinating my visit. If you know the American system it might come off as faux naive - but he meant it completely seriously:

"Do you have rounds where different specialties discuss the same patient together?"

Now, of course this happens occasionally. The New England Journal of Medicine's Clinicopathological Conference is a popular feature in that journal. "Tumor boards" involve meetings between different providers in relation to the care of the same cancer patient. But it's not a regular thing, at least in the general internal medicine division at which I practice at Johns Hopkins. Because there's no incentive to do so: any financial incentives to such a meeting of the minds would be outweighed by scheduling headaches. And yet, there they were, a hematologist, gastroenterologist, rheumatologist, and internist, sitting round a table, discussing a single patient.

Later, I was taken to Grand Rounds in one of PUMCH's oldest buildings, constructed in the 1920s. Rounds started in the lobby, in a way you don't often see anymore in the U.S., if at all: students crowded around a patient, being shown some bone abnormalities. (The picture I took purposefully obscures the patient.) Then we moved inside for a very technical series of lectures: another example of the ways in which, at least in this very privileged corner of the Chinese health care system, the direction of care has converged on the same priorities that are prevalent in the U.S.: narrowed expertise, a fantastic display of intellectual and research firepower devoted to the care of the individual patient with a rare, fascinating condition, of unclear relevance for the bulk of the nation's health.

I should mention an extracurricular activity: going to a bookstore. Not only a bookstore, but a large, iconic bookstore. What's more, it was packed full of people not mourning the demise of the written word, but purchasing it in many varied forms. I got a Chinese-Chinese dictionary, a phraseological dictionary, and a book of poetry by the modern Chinese poet Bei Dao.

Today I am giving a talk on public reporting of health care data and whether it matters to patient health. The audience will be made up, I am told, of doctors and administrators. Since public reporting is just getting started in China, I look forward to hearing their impressions.

I am exhausted, but before I drift off to bed here in Beijing I wanted to give an account of my first full day.

I sat in on rounds at Peking Union Medical College Hospital, my host and one of the top-ranked hospitals in China. The General Internal Medicine Division is renowned for its ability to treat the hardest cases and consistent high reputation, which becomes a self-fulfilling prophecy in certain respects (sound familiar?).

The similarities are not all that interesting: the team sits round a table and talks about the new patients, then walks through the wards seeing the old patients. Questions are asked to put medical students on the spot (in American English we have a word for that).

I should say that the patients on this ward had an extremely complicated mix of pathologies, mostly rheumatologic with some infectious disease and GI disease thrown in. I would have called for specialist consults on every patient were I treating them, and yet Dr. Yu Wang, of PUMCH, approached all with a calm, learned demeanor.

The differences I noticed on this brief first visit are somewhat instructive. In the United States, at least in the internal medicine programs I am familiar with, the senior resident runs rounds and the attending stands by the side to give a teaching point or a minor correction; here, it was the attending leading the discussion. In the United States, the entire team, in many hospitals, is by now acculturated to use hand sanitizer on leaving and entering every room. In the PUMC GIM ward, I was told by someone that I didn't need to use sanitizer if I wasn't touching the patient. Finally, in what is a sign of a developing economy or at least one not as electronic, the doctors entered orders in the computer but notes were kept on paper.

There was one similarity which was immediately evident: the hierarchy that hung over interactions between doctor and patient, and the great respect with which the patients treated the doctors every word (though the medical students I spoke to later expressed worries that patients no longer respected them). I don't understand enough Chinese to know whether the doctors were attuned to the patients' needs apart from their own particular workflow needs on rounds, but if these doctors are anything like many American ones, I can guess the answer...

* * *

Later, I had the great opportunity to give a presentation for medical students about bridging evidence-based medicine and patient-centered care, using localized prostate cancer as a case in point. We are trying to understand why patients with that most limited stage of cancer might leave an active surveillance (watchful waiting) program to get radiation and surgery which might not be clinically indicated. I will try to upload the presentation later.

We had a lively discussion. I fielded an expected question about what differences I noticed between the Chinese and American health care systems, after less than 48 hours of superficial experience with the former. I tried to demure, but one thing I did talk about was the overuse in the American system, over against the underuse in China which is prevalent for millions and millions of mostly rural poor. We also talked about what doctors might do when what patients want is against the best evidence.

After the lecture, I had a chat with a student of Uygur ancestry who was very interested in the role of religion in health care in the United States. I told him what I think is true: aside from end-of-life care and bioethics, the role of religion is underexamined.

* * *

Finally, I met a bioethicist, Dr. Yali Cong, from the Peking University Health Science Center (not to be confused with PUMCH, above. A city of 20 million, Beijing has a lot of hospitals!). We talked about one of the chief difficulties for those involved with clinical and research bioethics: the expectations of clinicians that bioethics will be able to give an "answer," where in reality what a bioethicist can give is an overview of possibilities, a mapping of the territory, and - in the most lasting influence - a habit of thought that even, or especially, non-bioethicists might benefit from.

* * *

It's been a great visit so far, and even after I leave China I hope to connect with people here through email and Weibo, my newest social media addiction made all the more interesting by the fact that my Chinese is a lot less than fluent.

PechaKucha is a presentation format in which the speaker tells their story in "less is more" fashion, using only 20 images and speaking for only 20x20 seconds. Thanks to Hillel Glazer and some other high-energy organizers, an evening of such presentations recently took place in Baltimore. Check out mine below, featuring Dante, the caduceus, and communication.

This week I will be giving a series of talks at the Peking Union Medical College Hospital, and even more important, learning how internists in that institution see their route to bridging patient-centered care and medicine’s evidence base. I hope to write about my visit daily, if not necessarily to post (that depends on internet connections and whether I can reach social media). Photos will come later.

It’s also an excuse to improve my execrable Mandarin. I know it is bad, despite the unfailing support and friendliness with which many Chinese greet my halting attempts at the language.

I love learning languages, though my success has been varied. I am old enough to remember what it was like to learn a language before Google Translate. An estimable tool, to be sure, one that facilitates looking up those fiendish arthropodian characters with 15 strokes.

Yet we all know Google Translate has problems. Sometimes, with all its fantastic power to make an educated, database-driven guess as to what the source text must mean, the translations stink. No human being fuent in that language would produce such a sentence.

Which is why Google Translate still needs supplementation by dictionaries. Of course, today’s dictionaries use much the same technology as GTrans: databases, search strategies. But they are curated, assembled by teams of lexicographers who are able to bridge the native expressions of one idiom with those of another.

I never shy away from analogizing, and you might have guessed where I am going with this.

Evidence-based medicine produces a number of studies. The best guidelines generate recommendations based on large datasets requiring considerable computational power, in order to model the interaction between various variables and the outcome of interest.

Yet we doctors and patients know that sometimes these guidelines, even those produced by the best science, come out with suggestions that bear faint resemblance to the options available to real human beings living complicated lives – the same way that the frictionless surface beloved of physicists is a crude approximation of sublunar life.

By now it is a cliché to say that the art of medicine is a language in itself.  That’s not quite what I am saying here. Only patients are fluent in their own languages: idioms of body, society, family, daily life. Together, providers and patients can function as an expert lexicographic team, bridging the ever-improving, but still sometimes outlandish recommendations of Google Medicine, with the diverse speech of real human beings.

Dr. Google, meet Professor Wittgenstein. 

I haven't written much about parenting, because most of it is hard and boring. Like maintaining health, either as a doctor or a patient, it's usually a slog, requiring wellsprings of confidence to remain sure that what one is doing in the moment will have some measurable impact down the line. To that end, I have decided to found an organization to inspire such confidence, while establishing standards that can make most of us - the average parents, the pretty-good providers - feel supported in the slog. It is called the Adequacy League, and will have at least two arms, one for parents, one for physicians and patients.

The League of Adequate Parenting will emphasize that most of us who bellyache about child-rearing, and fear that we are not doing well enough, are actually doing just fine given our circumstances. This means, of course, that if we are parenting in resource-rich circumstances, we should appreciate that fact: our adequacy is not likely to be the same as that achievable under other circumstances.

Similarly, the Adequate Doctors-and-Patients' Union recognizes - by charter! - that there is a tension to medicine. On the one hand, much of what ails us gets better with time, and we ought not to interfere with that. But, on the other hand, we want to actively interfere in a great many conditions for which there is no "natural" cure. Adequacy means neither interfering without exception on principle nor refusing to intervene on the basis of some misguided alliance with "nature." Neither doing too much nor too little, and not looking over one's shoulder continuously at the latest study. The adequate doctor or patient can be satisfied with her efforts toward health even as she knows she is not perfect.

Adequacy does not mean complacency, but the ability to take stock of our current limitations, appreciating all we are managing to do.

Excellence can be quantified, sure, and we should all aspire to it. Poor performance can be avoided as well with the help of keen analysis. But neither striving for excellence nor avoiding error and harm can get us through a weekday morning, a whiny toddler, a chronic illness, a day full of things-to-do and people with quite legitimate demands whom we need to serve. Sustaining a notion of adequacy is key. The Adequacy League recognizes this. Though it presents no awards, reimburses no one for travel expenses, and has no meetings, it will exist, quietly, wherever you are, as long as you need it.