Jackie Xu, Duke University
This past US summer 2017, I studied with Tiantan Hospital in Beijing, China. “Tiantan” means “Temple of Heaven”, referring to the hospital’s close proximity to the tourist site—though I think it is a fitting location for a healthcare center as well.
Walking through the glass doors of the Tiantan’s stroke center research unit on my first day, I was amazed by the depth and breadth of healthcare work concentrated in one location. The hospital itself is a restless place with patients constantly streaming in and out, and Tiantan has also set up a vibrant learning environment for its trainees. The entire stroke unit meets every morning to review patient cases together. Every other week, the director of the neuro-intensive care unit leads journal clubs. I was fortunate to have such a supportive environment to learn and explore, working with students, clinical trainees, health care providers and faculty at Tiantan and its affiliated Capital Medical University on understanding stroke care in China through two research projects – one quantitative and one qualitative.
After taking a few days to settle into my summer home, I approached my Tiantan mentors with my qualitative research project plan. This was a project to understand how to increase stroke patient medication adherence from a health systems perspective. Data from the Chinese National Stroke Registry and other stroke cohorts already identified adherence as a problem. My question was, “What are the system barriers and facilitators to improve stroke patient medication adherence after hospital discharge?”. This included a plan to complete interviews to collect opinions and perspectives from multiple people with roles aligned with this problem—including patients, acute and community-based healthcare providers, pharmaceutical company representatives, and Ministry of Health officials. The idea of a qualitative study received mixed responses from the clinical research mentors.
On the one hand, my mentors were interested in exploring qualitative methods, not commonly used in China’s medical research practices. On the other hand, they worried about the level of rigor in qualitative interview methods and expressed concern over the ability to publish results with this type of data.
At first, it was frustrating to receive this feedback. Although I am an undergraduate student with little prior experience related to stroke, the data spoke for itself—medication adherence is a pressing issue for stroke patients in China. Previous studies led by Tiantan faculty demonstrated a need to understand system barriers and means to improving medication adherence. I held the rooted belief that I had an important research question, vital to improving the lives of stroke patients in China. Yet at the same time, I knew that I didn’t have the full picture. My position both as an undergraduate student and an outsider to this community left me doubting myself about what I didn’t know.
However, as I learned more about the research landscape in China, I came to a greater understanding of Tiantan leaderships’ perspectives on qualitative and quantitative research. Despite China’s extraordinary economic and technological advances, the quality of research coming out of China is still being scrutinized[i]. In efforts to clear doubts over data validity, clinician scientists in China put forward Herculean efforts to master English and apply for prestigious fellowships abroad, maintain an 8am to 8pm work schedule, employ personnel to support improved data quality, and manage large clinical and research infrastructures proportionate to the size of the population (really large). Yet, research from China still remains under question.
Contextualizing my environment propelled me to build the case for qualitative research as a valid and valued method of study with Tiantan and its affiliated students and faculty. I presented the journal club’s first qualitative study, answering many questions afterward. I branched out of my immediate Tiantan network to build a team of project advocates. Along the way, I listened to concerns of clinicians and was mentored for a related quantitative study on medication adherence post-stroke. We successfully exchanged research knowledge and experiences.
Both projects came to fruition. Shadowing at inpatient units and outpatient clinics, traveling to facilities around Beijing for physician interviews, and eating too many takeout dinners on late nights with my fellow colleagues, I felt like I had truly begun to understand the complexities of the Chinese healthcare system.
I found that at the core, people at Tiantan were open to new ideas. Inhibitions stemmed not from fear of novelty but a yearning for professional respect—co-workers with paralyzing scares of data falsification, journals focused on research from prestigious Western institutes, and a “globalization” driven and dominated by developed countries. For China, gaining mutual respect from colleagues was an evolutionary process.
This summer, I served as an ambassador from my American-based university and navigated this new and sometimes enigmatic partnership between two leading healthcare institutions—Duke and Tiantan—separated by the Pacific Ocean. My work advocating for qualitative research methods in China taught me how to identify project champions and engage key stakeholders. Collaboration, and therefore mutual respect, is the key to research.
About the Author:
Jackie is a Chinese-American junior at Duke University studying Public Policy. Jackie is passionate about creating systemic, sustainable change for healthcare systems around the world. She serves on the Global Alliance on Disability and Healthcare Innovation (GANDHI) research team, headed by Dr. Janet Prvu Bettger at Duke. Jackie loves meeting new people, so feel free to reach out with questions, comments, or reactions at Jacqueline.firstname.lastname@example.org.