The Dark Side of Overtreatment
If oral medicine will do, do not inject; if injection will do, do not infuse — detailed history-taking, careful physical exam — these should be the standard medical procedures. Yet today the standard procedures have long been replaced by the best drugs, the most high-end tests, the most advanced surgeries, and the highest fees.
Two years ago Zhang Chunlin, nearly 70, with effort-type angina, came to a major Beijing hospital. Diagnosed as serious, on the doctor's recommendation he underwent coronary-stent surgery. Yet in only one year and two months, two stents blocked his vessels and brought on acute myocardial infarction. His daughter — a cardiologist abroad — looked at her father's angiography disc from more than a year before and found his condition then was mild angina, manageable with medication.
Cases like Zhang's are far from rare. Stent surgery has a high rate of intimal proliferation afterward. In 2010, a Beijing tertiary hospital put several stents into a man over 70; he died the day after surgery. In October 2009, a Beijing tertiary hospital pushed in 8 stents on a vessel that could not even take them, and the patient died of cardiogenic shock during the overlong surgery. A Chengdu cardiology hospital put 17 stents in one patient. Such putting in stents that should not be put in is, in medicine, a lifelong, one of the most serious overtreatments. Yet in 2008 alone, about 188,000 Chinese received coronary intervention — how many of these were nonstandard? The chief reason for stent overuse is economic. A domestic stent costs 20–30,000 RMB; an imported one over 30,000. It is a major part of hospital revenue. In 2002 Johnson & Johnson's stent entered China priced at 36,000, with distributor margin of up to 50%; the share of its use in domestic stenting reached 98%. Meanwhile a Boston Scientific (US) stent priced at 18,000, with use rate 60–70% in other countries, sold essentially zero in China in six months. Another reason: a doctor must perform stent surgeries up to a certain number to publish one paper; to gain senior title, three papers in core journals.
Almost no one any longer follows what treatments fit what conditions. The 2009 China Health Yearbook: outpatient diagnostic-and-treatment fees at integrated hospitals rose from 2.1 RMB (1990) to 35.1 (2004) to 45.3 (2008); per-discharged-patient diagnostic-and-treatment costs (including surgery) from 121.5 (1990) to 1,566.3 (2004) to 1,887 (2008). Antibiotics, for instance: in some large US hospitals, heart-disease surgery requires no antibiotics, on the view that needing antibiotics in a sterile field shows the doctor incompetent. In China, inpatient antibiotic use rate is 80%, directly raising Staphylococcus aureus resistance to penicillin to 90% and to cephalosporins to 30–40%.
A survey in a Shandong county compared random outpatient prescriptions for the same illness: county-level hospital prescriptions contained two drugs; village-clinic prescriptions four. In the village clinic — a place where injections are not even recommended — injection use rate in prescriptions reached 63%. Data show 85% of drugs in China are sold by hospitals.
Overtreatment also shows in tests. One: insufficient hospital funds, so to improve conditions revenue must be drummed up. Two: doctors' self-defense, to avoid the trouble of a medical incident, leads to overtesting. Of 300 general physicians surveyed, 98% admitted to overtesting — its purpose only to avoid lawsuits.
Experts say: to solve overtreatment, first set the standard for overtreatment; then build a third-party regulatory mechanism and network; reform the hospital system, making public hospitals truly non-profit. We also hope patients become informed care-seekers, choosing as far as possible the simple-convenient-cheap-effective TCM, dodging overtreatment, securing their own rights, and obtaining true health.