China’s 30-second diagnosis secret

A commentary by EL: How China’s hospitals make do without general practitioners

View from China with an Austrian School of Economics Perspective

This is Part 2 of our series on the pluses and minuses of China’s medical system. Part 1 is here.

Fast forward ten years

In the intervening period China’s hospitals have acquired ever more gadgets. Many of the hospitals also became far more efficient and convenient, with short waiting times to see doctors and test results available online. Those with a local social insurance card can even save themselves the trouble of getting a card for each hospital; the social insurance card (社保卡) does the trick for all of the public hospitals and even a few of the smaller private clinics.

And yet, the core problems remain the same.

Several years back a former colleague almost died due to the persistent failure to translate patients’ description of symptoms into preliminary diagnoses. Two weeks after giving birth, she had terrible abdominal pain, exhibiting all the symptoms of acute appendicitis. The catch was that her pain was in the wrong place. Her appendix ended up bursting and she went into a coma. She narrowly escaped with her life. Eventually a doctor finally decided to do exploratory surgery to get an answer using the crude approach, only to discover that her internal organs had been substantially relocated by her pregnancy. Imagine that. Talk about a failure of imagination. This would not have happened if her doctors had listened more carefully to her description of her symptoms.

A diagnosis team in a Chinese hospital

When one comes into a Chinese hospital, there is a typically an ‘information desk’ (咨询台) in the lobby area where you can go if you don’t know which specialist to see. The girl there is China’s version of what in English-speaking countries is called a general practitioner, with the not insignificant difference that you rarely get more than 30 seconds from her before you are given a tiny scrap of paper on it with the name of a department on it. But what if you just have a fever, or are simply feeling bad?

Now that’s a problem. There are zillions of possible causes, and expecting that girl at the information desk to guess correctly requires a good bit of wishful thinking. During the Covid years, if you had a fever you got sent to the fever clinic, where their primary focus was on diagnosing Covid-19. If you didn’t test positive, then they were usually nice enough, but did not typically have much to offer.

As usual everything revolves around tests. But which ones? After all, in most hospitals a lot of tests are available, and hospitals have a monetary incentive to do as many of them as their doctors can conceivably justify. Given this reality, perhaps it’s logical that doctors aren’t encouraged to listen to patients. Instead of using information from the patient to help come up with a preliminary diagnosis and then testing to confirm this, a shotgun-like approach seems to be favored – first write up a bunch of tests, then… 再说. I.e. we’ll cross that bridge when we get to it.

The result? In many cases the doctors don’t even bother to look at the results.

Unsurprisingly, with limited input from the patient and limited interest in the results, you may end up with a vague diagnosis (if any), and a recommended course of treatment which doesn’t work.

Again, keep in mind that we are not talking about all cases or doctors here. Not all doctors are equally bad, and not all cases are equally unclear. If however you are one of the less lucky ones, after going through a couple of specialists, here are some of the common ‘diagnoses’ which you might end up with:

• ‘亚健康’ – suboptimal health

• ‘精神病’ – mental illness, for example due to stress, i.e. you’re a hypochondriac and are imagining things

• ‘不明原因发热’ – fever of unknown origin

I have gotten all of these diagnoses at some point over the years. The ‘mental illness’ diagnosis I got twice back in the years when I was struggling with leaky gut, including once at a pricey private hospital. Needless to say I didn’t go back.

In 2021 I had one of those off-and-on low fevers of unknown origin, one that responded to antibiotics but not to the tests.

Even today I still am not yet sure I found THE cause, but after two years of searching I definitely found A cause. Once again, I had to figure it out on my own.

I’ll share that story, because it illustrates a number of the failings of the system.

One Two Three Four Five Six Doctors

The key clue, if I can call it that, ‘cropped up’ a few months ago – a nasty intestinal cramp which got started one night and continued until the next morning. This happened several times, always starting in the evening hours. I think it was the second time around that I vomited a lot of undigested food around 5am, after which the cramping fairly quickly went away again. This should have been a big clue as to what was going on. With these clues in hand I trooped off to my local 三甲医院, a top-tier shiny public hospital with all the latest gadgets. I dutifully paid the 6 RMB fee to see a young internist (Doctor #1). There was no waiting and he was nice enough. He suggested an endoscopy, but agreed to prescribe me some medicine for stomach problems to see if that did the trick – one Western and one Chinese. My public health insurance paid for everything.

The Chinese herbal medicine turned out to be useless, for reasons which will become clear later.

The Western ‘medicine’ turned out to be a proton pump inhibitor (PPI), which decreases the amount of stomach acid and is often prescribed to deal with acid reflux.

Among both practitioners of Western holistic medicine and practitioners of Chinese medicine (TCM), proton pump inhibitors are often seen as fraudulent and in fact counterproductive. However, the pharma companies make lots of money off of them, and they pay hefty kickbacks to the decision makers who set the treatment policies at hospitals.

That said, even if they do work, I didn’t have acid reflux.

Doctor #2

At the same hospital I also went to see a TCM practitioner (Doctor #2). She told me to toss the PPI. Since my symptoms were not even remotely similar to acid reflux, I took her advice.

Unfortunately, her brewed Chinese herbal medicine didn’t work either. In fact, not only did it not work, but it actually provoked an allergic reaction, so I had to toss that, as well. Another 700 RMB (~ US$100) wasted, paid for by social security.

Doctor #3

I then tried acupuncture at a private TCM clinic (Doctor #3) targeting the stomach. That didn’t work, either, which as we shall see, was unsurprising because the stomach wasn’t the problem. More money wasted by social security.

Doctor #4

When I saw Doctor #4, about a week later, I again mentioned the undigested food. She suggested trying a medicine to promote intestinal motility. Though I have never before had any stomach issues, based on my very limited knowledge at the time, this seemed a reasonable suggestion. So I tried it. I also combined it with some digestive enzymes, and that actually seemed to work – at first.

I had no more attacks for a few weeks.

Doctor #5

Then came attack #4. That was on a Saturday night, and also involved undigested food.

This attack sent me back to the hospital for yet another attempt to get a correct diagnosis. On Sunday the only doctor available was a ‘特需门诊’ – an expert whom I actually had to pay for, costing several hundred RMB.

As is so often the case with these ‘experts’, it was an elderly woman (Doctor #5) surrounded by two young acolytes eagerly scribbling down every own of her words. I repeated my story with all the clues I had accumulated up to that point.

She did not seem interested.

Instead, she insisted on that I absolutely needed to do an endoscopy, pointing out impatiently that there could be a blockage we needed to know about. The fact that most of the time I had absolutely no digestion issues at all did not interest her. She also wanted me to a do a bunch of blood tests and a CT scan.

All of that got entered in the computer, plus a prescription for the same (useless) Chinese herbal powder for stomach issues which Doctor #1 had already prescribed.

Not only did she fail to come up with a preliminary diagnosis, but even more frustratingly, she had no medicine on offer to deal with the actual immediate problem, which was the terrible cramping. When I asked specifically about this, she brushed me off, saying that the important thing was to first figure out the cause.

The total cost for all those tests and the useless Chinese medicine was around 1,200 RMB, most of which to be paid for by social security, of course. However, it wasn’t possible to do any of those tests on Sunday anyway, so I returned home untested.

Back to DIY

It didn’t take me very long to figure out that her logic about the potential ‘blockage’ made no sense. And at that point, facing the prospect of more painful nights, I went back to my computer to try to figure it out on my own.

I figured it out.

How? Somehow I discovered that there is a more technical word for what I was calling a ‘cramp’ (痉挛 or jìngluán in Chinese): a colic, a term typically translated with ‘绞痛’ or jiǎotòng in Chinese). This is a word that many English speakers associate with whiny babies, but it has a distinct – and quite ancient – medical meaning. It refers to a spasm of the intestine. It comes from the word ‘colon’ and has been referred to using this term across all of Europe for over 2000 years. I mention its history only to underline the fact that this is anything but an esoteric phenomenon. On the contrary, this phenomenon is so well known and so common that the same term has been in use during that entire period.

And yet, from my descriptions apparently not a single one of those doctors managed to figure this out.

As soon as I tracked down the term ‘colic’, I looked up what medicines were available to deal with colics in China and ordered one from Meituan Maiyao (美团买药) the same day. It’s called Dicetel (‘匹维溴铵片’) and for around 30 RMB (~US$4.30) I had it in my hands by late that Sunday afternoon. Dicetel has the disadvantage that you have to take it as a prophylactic, but at that point I wasn’t exactly very picky.

It seemed to work – no more cramps.

Next task: Come up with a hypothesis about the actual cause. Reading about colics I learned that spasms can happen in the large intestine, the small intestine, and/or in the gall bladder. So which one could it be? After reading a number of articles, I finally found one with an answer: Colics which consistently occur at night are typically caused by gall bladder issues.

What seemed to be going on was that high levels of fat in the stomach could lead the underperforming gall bladder to trigger a spasm. When this happened, my pyloric valve (the exit from the stomach) would freeze up, thus creating a traffic jam. If the traffic jam lasted long enough, at some point the stomach would fill up and cease its efforts to digest food.

Doctor #6

With this hypothesis in hand, several days later I was back in the hospital. I paid my 6 RMB to talk to Doctor #6 and asked to get an ultrasound of my gall bladder. 30 minutes later I had my confirmation. The ultrasound guy took about 5 seconds to tell me: You have a gall bladder problem.

Yep.

Well, there you have it. Actually the ultrasound guy told me more than that, but the key point here is that I had to come up with the preliminary diagnosis myself.

Six doctors with all their experience were unable to guess at this. And not a single one offered me anything to suppress the symptoms. Perhaps they really don’t know.

To be continued in Part 3 — Lessons to be learned.

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