Chouwen Zhu, MD, MSc, President, Director, and Chief Physician for Shanghai Clinical Research and Trial Center, shares his perspective on the development of integrating evidence-based medicine into health care delivery in China to improve care delivery. Health care resources are limited, and health care needs to use these resources more efficiently and effectively. Evidence-based medicine is a guideline for health care delivery to achieve these goals. Another issue is the large size of China, which poses a challenge in spreading the adoption of innovative practices. Major cities house advanced facilities in the top hospitals, but there needs to be outreach to the rural and underdeveloped parts of the country to improve health care quality. Innovations including online distance learning for physician training, an improved referral system, building more hospitals, and remote monitoring for patients help to bridge these gaps. But this is still not enough, Dr. Zhu says. He also provides examples of research initiatives that have successfully influenced clinical guidelines and care in practice, but he cautions that more research needs to be conducted and shared to make health care more effective, less costly, and to shorten diseases or prevent them altogether. Dr. Zhu says that modern medicine requires teamwork, and that multidisciplinary treatment approaches are very common in China. He also describes the different levels of medical education that help to ensure future and current health care providers are equipped to implement cutting-edge evidence-based medicine. Lastly, Dr. Zhu points to the changes needed to better integrate research-backed approaches into health care, including through the Healthy China national strategy; the need for hospitals to provide not only health care, but also to conduct research in their facilities; and for doctors to follow international guidelines for their research.
Thomas H. Lee, MD, MSc, interviews Chouwen Zhu, MD, MSc, President and Director of the Shanghai Clinical Research and Trial Center.
Tom Lee:
This is Thomas Lee, Editor-in-Chief of NEJM Catalyst. I’m delighted today to be having a conversation with Professor Zhu Chouwen, who is the chief physician, professor, and President at the Shanghai Clinical Research Trial Center. The reason we’re having this conversation is that we all know that you cannot improve without learning, and you cannot learn without research.
We are delighted at NEJM Catalyst to be collaborating with colleagues in China to be supporting the development of integrating evidence-based medicine into health care delivery in China. Dr. Zhu has performed a leadership role at many different levels in the development of research and the application of it in clinical care in China. He has an incredibly interesting background, which includes a brief time as a student in San Francisco in the United States at UCSF [University of California, San Francisco], but he has been international and working across parts of the world and the health care system in so many other ways.
He has training in epidemiology and gastroenterology, but he has been working in clinical research, clinical epidemiology, and clinical trials in China on many different levels and is playing a key leadership role today in Shanghai’s Clinical Research and Trial Center. So, he is the ideal person to be commenting on these topics today. Dr. Zhu, can you elaborate on why integrating evidence-based medicine is crucial for improving health care delivery in China? From your perspective, what specific benefits are you observing in patient outcomes?
Chouwen Zhu:
First of all, thank you, Tom, for your kind introduction. I’m glad to be interviewed in this way, to give some introduction about the evidence-based medicine we should be practicing in China, which, especially as you said, that is very important to improving health care delivery in China. I’ve learned clinical epidemiology and evidence-based medicine about 30 years ago, which is a research methodology, and the application of the result using this research methodology into clinical practice. That’s evidence-based medicine, which shows all the ways that you perform in your medical practice should be evidence-based. It’s not just as freely by your thinking or by your guessing. You should get the evidence, you should get the profound evidence to guide your diagnosis, to guide your treatment, and even to guide your prediction of the prognosis.
Why this? Because, as we all know, health resources are limited. How to use these limited resources first in terms of efficacy, and secondly in an effective way, and then in an efficient way? That shows the importance of how to use the resources more that is also economical in this way. So evidence-based medicine is, you could say, a guideline for us for health [care] delivery, which can help us to achieve these goals effectively. Firstly, the efficacy, effectiveness, then also efficiency. That’s important not only because the health resources are limited, but also you want to show as much of the benefit for the patients from the health providers, that is, to do more benefit than harm to the patients [you] definitely need evidence to support you.
As we all know, health resources are limited. How to use these limited resources first in terms of efficacy, and secondly in an effective way, and then in an efficient way?
That’s why I think anywhere, also including China, we have to do it this way. Another issue that we have to consider is, China is so large. [For example,] in Shanghai or in Beijing, we have very top hospitals. We almost have all the top advanced facilities in the hospitals. But how about in the rural areas of China? How about in the border area? In the undeveloped area in China? How can they improve the quality of health delivery based on evidence-based medicine that’s under practice? It may not be the same as those in the large cities, but still we can show them the guidelines with the evidence, and also they can find where the expertise can be the most appropriate for the patients. That’s the kind of evidence-based medicine that can practiced in the local area and also surely in the very top area in China. [Those are the points that are] important for evidence-based medicine, for health delivery in China.
Lee:
You bring up something really interesting and important, which is that China is so big and so varied that it has a greater challenge than we have in the rest of the world in spreading the adoption of innovative practices. We all have that challenge [in the United States], but you have it in much greater magnitude. How are you taking on that challenge effectively?
Zhu:
Innovation is all along our way to developing medicine, but also in other sciences as well. Innovation including that we use the most advanced technology, and the facilities, or devices, or the agents that can make the diagnosis and the treatments. But also innovation in how to organize our health delivery system.
That’s also important, in China, and I believe in other places around the world. The health care providers in China — as I said for the last question, we are lucky that we are working in large cities, in large hospitals — can use all the [world-class] guidelines and world-class facilities, the world-class level facilities to provide our health care and also for prevention as well. But in the rural area, how can they achieve the way to give better health care to the patients and for the families?
Another issue that we have to consider is, China is so large. [For example,] in Shanghai or in Beijing, we have very top hospitals…. But how about in the rural areas of China? How about in the border area? In the undeveloped area in China? How can they improve the quality of health delivery based on evidence-based medicine that’s under practice?
That is also important for the innovations or innovative ways in the health delivery system. Now we can use distance learning, online 5G, and all these things, and even remote control for this, but we also can have very good delivery chains to these rural areas. We can make the referral system that much more effective, and we can train the doctors in these areas more effectively face-to-face and also through online. Those are some innovative practices in medicine, in the health care field.
These are the kinds of challenges in China that we are working with, and I think we also achieved a lot. For instance, the very important indexes for quality of life, life expectancy, infant mortality rate, and maternal mortality rate in China are really, really low, compared to the world level, even compared to the most developed countries.
With the gap between the cities and between the rural areas out there, we try to make the gap smaller, and that not only means that we have to physically build larger hospitals in these areas, but also that we’ll also make it through the new technologies, maybe online, and also the referral system, and even with all this education we can achieve this [to meet] the kinds of challenges that we are working with. But it’s still not enough. The life expectancy in the larger cities comparing to life expectancy in the rural areas, still there’s a gap, even in some places a huge gap. That means we still need to do a lot of work.
Lee:
Your points are very good. Organization matters, the use of technology matters, and having education really matters. These are lessons that I hope are going to be useful for our listeners around the world. Let me turn to the next question, which is, how does ongoing clinical research in China contribute to the integration of evidence-based medicine into practice? Can you provide any examples of research initiatives that have successfully influenced clinical guidelines and care in China?
Zhu:
Well, I said innovation, not development is along the way in medicine. Even though we have great achievements in health care, in some ways it is still not enough. How we can make it more effective, how we can shorten the period of the diseases, and how we can make the suffering less and give the patient more comfort, and be less costly, that’s also important for us to sustainably provide health care. That needs research.
With the gap between the cities and between the rural areas out there, we try to make the gap smaller, and that not only means that we have to physically build larger hospitals in these areas, but also that we’ll also make it through the new technologies.
This research, these questions, should be based on our clinical unmet medical needs, but also be based on the development of basic medical research and basic bio research as well, and also the development of materials, of engineering. We will integrate all this into the ultimate user in medicine. That’s for patient care, not for population care and population health. The ongoing clinical research [for population health] is definitely important to get more cost effective and cost efficient for health care delivery.
To give some examples, hypertension is a very common disease and diabetes is also a very common disease. But a lot of research has shown how to control that, not only the pills, but also your lifestyle, your integration, your surveillance. For all of this, we use guidelines to give the patient not only care inside the hospital, but for their family, for the community we show all these effects. Even in the hospital, the VTE, the venous thromboembolism, was a very severe situation previously, especially for the operation patients. Now we know the importance of that, how we can control this life-threatening disease.
We do a lot of prevention work and education work not only for the doctors, but also for the patients, the clinical doctors, the nurses, the managers, and the family members as well. We have different kinds of devices and video education, and all these can be provided to the patients and to their family members, and to the doctors.
That shows that we can really do this because we know the mechanism, we know the pathogenesis of the venous thromboembolism; with this data we can then control this. This also shows if you want to make new approaches effective, you have to know the pathogenesis, you have to know the mechanism. That’s very crucial. That’s also very basic. That’s the basis of development for any kind of effective innovation.
Lee:
I’m delighted to hear that hypertension and diabetes were the very first two topics that you mentioned, because we both know from our epidemiology training how Chinese are particularly vulnerable to those two conditions, and spreading knowledge of how to treat them is so important from a public health point of view.
Zhu:
[Another] disease [example is] Helicobacter pylori, that’s in my field. I’m a gastroenterologist, and HP (H. pylori) is a cancer pathogenesis factor. Now, it’s not only the GI doctors who know the importance of that. Now, the oncologists also know the importance. The GPs (general practitioners) also know that. And the nurses also know that.
Even though we have great achievements in health care, in some ways it is still not enough. How we can make it more effective, how we can shorten the period of the diseases, and how we can make the suffering less and give the patient more comfort, and be less costly, that’s also important for us to sustainably provide health care. That needs research.
In China, we don’t have a [generic] screening test, but for the patients with upper GI discomfort or these kinds of issues, we do the endoscopic tests, the breathing tests, and even the 13 carbon (13C urea breath test) tests. We have all kinds of tests for the patients to try to decrease the infection rate of this. But we also need education for the family members and for the community. That’s the way to control this. Because surely no one wants to have gastric cancer, and we have to do more prevention work.
Lee:
Yes, and one generation ago no one knew about Helicobacter and patients would just suffer. But spreading that knowledge and actually helping people is so possible today. You mentioned nurses know about this now, and that leads me to ask, how is the work of fostering interdisciplinary collaboration among health care professionals going in China? Is it enhancing the adoption of research-informed practices? What is happening in China to encourage such collaboration?
Zhu:
Modern medicine needs teamwork. That teamwork is based on different kinds of discipline, the doctors and also the nurses, and the health providers with different academic and practice backgrounds. No one can achieve such a goal by himself. It’s totally different. We have our disciplines, and we have our subdisciplines that make it very deeply focused on one kind of disease, even one subtype of these diseases.
Facing the patient, not only are we facing the disease, but we need to think more about side effects and about the patient’s general condition. The subspecialist may be very focused on this, but sometimes he is not so well prepared. Though he learned all these issues, during practice he may not be so well prepared for the general conditions that a patient may face, and if there are some comorbidities, we need colleagues to work with.
Multidisciplinary treatment or multidisciplinary approaches are very common in China, not only for cancer patients, but also especially for the elderly people and especially for the patients with different kinds of complications. We are doing this quite often. Sometimes it’s a routine way for difficult cases and for the patient. Give them a comprehensive evaluation, give them the comprehensive approaches and the comprehensive treatment protocol, or follow-up protocols for the patients that can help the patients not only face the disease, but also improve or maintain their quality of life, and work with the family members.
If you want to make new approaches effective, you have to know the pathogenesis, you have to know the mechanism. That’s very crucial. That’s also very basic. That’s the basis of development for any kind of effective innovation.
That is now quite routine in the large hospitals in Shanghai or in Beijing. Even in the small regions, we can have online consultations to make this happen. Like in the United States, the human resources are quite costly and the doctors are also costly. We may train health assistants and nurses to do this job for the follow-up and in different ways. That [helps to] save resources and give better health care for patients.
Lee:
I love that you said you cannot have modern medicine without teamwork. It is so true, and there are many, many physicians throughout the world who haven’t quite grasped that yet. But I’m so delighted to hear you state that so strongly.
How is the training and education of the next generation going in China? How are you working to make sure that the next generation of health care providers are going to be equipped to implement evidence-based medicine? Are there specific programs or initiatives that have been particularly successful?
Zhu:
I can say yes. We have evidence-based medicine or clinical epidemiology and their research methodologies, these regular courses for the undergraduate. In China, our medical education is mostly studied from graduation of high school, not like in the United States. We have the 4+ (4-year) program. Wherever they are in their bachelor study time, or in their master, or MD, or the PhD training program, we conduct different levels of evidence-based medicine or clinical epidemiology and try to get the future doctors to know the logic of research, the logic of the consequence of this research, and the logic of how to apply these research results into your clinical practice.
We also have medical associations for evidence-based medicine, and the physicians’ associations of evidence-based medicine that give promotions and continuing education, annual conferences, and workshops for the doctors offline or online. We also have some special workshops to teach them how to apply evidence-based medicine into their daily work. So, we have all kinds of trainings and education, some even with degrees, for the health professionals.
Lee:
That is very impressive. The younger students are learning how to learn, and then they’re learning how to organize and how to work together and how to actually implement the learning. Both are critical, obviously.
Zhu:
Yes.Modern medicine needs teamwork. That teamwork is based on different kinds of discipline, the doctors and also the nurses, and the health providers with different academic and practice backgrounds. No one can achieve such a goal by himself.
Lee:
To wrap up, looking forward, how do you see research-backed approaches transforming health care in China? What are the changes that you feel are needed in health care systems in order to better integrate these practices?
Zhu:
That’s quite a big topic. As we discussed, research is important to keep medicine [moving] forward, to keep our society healthier, and to deliver these new achievements to health. Healthy China is our national strategy, proposed by our central government, and everyone knows it’s important. We need to make our health care delivery system more effective and more efficient.
This is based on the research results that we have, but also, as we discussed, by these well-organized organizations to conduct [the research]. In China still, in most of the hospitals, their main job is to provide health care, not research as their main task. But we need some top hospitals or even in some part of these hospitals to do this kind of research, which is aiming for cutting-edge developments, to have more innovations to get to know the pathogenesis of the diseases, so that we can conduct something to change that, to stop that, or to change the ways of the disease development such that we ultimately change the prognosis of diseases.
Sometimes in prevention, in a very early stage we’ll do that, at least based on the research. But, as I mentioned, clinical research needs methodology. It’s not only by what you want to do, but you still have to follow the common guidelines that are recognized internationally.
As a research methodologist, there are no Chinese characteristics. There’s the global standard. If you want to do the research, which you want to be recognized by international society, you have to follow the guidelines. There are not any exceptions for this.
In China, more of the doctors who want to do clinical research have to follow these guidelines. If you want to apply the research result into clinical practice, you also have to follow the guidelines. If these guidelines are well followed, the results will be reliable and also be valid — that’s very crucial. That’s really, really crucial, to be recognized by international society. Reliability and validity are the targets that we’re facing if we want to do these kinds of research. If we conduct all this research, and use such a high standard, but actually it’s a basic standard as well, this can help our health systems be more effective and more efficient.
In China still, in most of the hospitals, their main job is to provide health care, not research as their main task. But we need some top hospitals or even in some part of these hospitals to do this kind of research…to have more innovations to get to know the pathogenesis of the diseases, so that we can conduct something to change that.
Lee:
Dr. Zhu, I want to thank you so much for your comments, which I found very inspirational, and also they have a great deal of value for the rest of the world as well. Because the challenge of creating a healthy China is so big, it forces you and your colleagues to think very clearly about what is required to make progress toward that goal. Clearly, part of it is advancing medical science and learning what is supported by evidence, such as the example of Helicobacter that you brought up.
But then there is the work of translating that knowledge into better care that is reliable, that actually helps a vast population benefit from that knowledge. And you and colleagues with a similar orientation are working in that space in between evidence-based medicine and highly reliable delivery of care and working across sectors with public health and education.
I think we and the rest of the world have much to learn from what you are doing, and I’m hoping that you will come back and share your insights through NEJM Catalyst with the rest of the world as well as with your colleagues in China. Thank you again for your time, and I do look forward to interacting with you much more in the years ahead.
Zhu:
Thank you, Tom. Thank you for your interview. I’m also looking forward to working with international societies for health, ultimately for the people’s health and for a better world. Thank you so much.