JRSM >
Volume 94, Number 4 >
Pp. 190-193
Eastgate House, Hockering Road, Woking, Surrey GU22 7HP, UK
E-mail: carline{at}doctors.org.uk
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 TOP INTRODUCTION THE HEALTHCARE SYSTEMOTOLARYNGOLOGY PRACTICE IN RURAL...REFERENCES |
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| THE HEALTHCARE SYSTEM |
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TOPINTRODUCTIONTHE HEALTHCARE SYSTEMOTOLARYNGOLOGY PRACTICE IN RURAL...REFERENCES |
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With the introduction of market reforms the health system was decentralized5, local governments being given more responsibility for providing services. However, most of the running costs of the hospitals must now be met by user fees generated in the hospitals themselves. Greater autonomy allows them to invest in equipment and pay bonuses out of any extra income earned. Basic healthcare, such as consultations, inpatient stay, and simple operations, must be set below cost. The profits come from drug prescribing plus high-technology investigations and treatments, such as ultrasound, computerized tomography, magnetic resonance scanning and intensive care.
These incentives lead to excessive drug prescribing and overuse of expensive investigations3. Another reason for overprescribing is the expectation of the patients, many of whom feel they have not been treated properly unless they have been given a prescription. Because of lower funding for preventive services, disease prevention is being neglected in favour of curative services that provide more income5. Therefore the incidence of tuberculosis and schistosomiasis is increasing in rural areas. Healthcare inequality has been recognized by the Government, which in 1994 began a pilot project in fourteen counties of seven provinces to reinstate the rural cooperative medical system. An evaluation of the results showed room for improvement, but much was positive and the scheme is to be considered further6.
In China there are three levels of doctors7. Barefoot doctors, now called countryside doctors, came into being during the cultural revolution when many qualified doctors were sent to the countryside for labour. There they were able to train the barefoot doctors. Countryside doctors now receive three to twelve months' training from county hospital doctors and the emphasis is on learning to manage common diseases that will be encountered at village level. The next level up are those trained at health schools, many of which are located in rural areas. The students usually enter these health schools after middle school and train for 3-4 years. They form the majority of doctors working in the rural hospitals. Finally, there are doctors from university medical schools, which take high-school graduates and train them for 5-6 years. Few of these top-level doctors will go to rural areas. They tend to work in the city or larger county and provincial hospitals. Almost 70% of China's population lives in rural areas8, which are clearly underdoctored by comparison. Traditional Chinese medicine is a separate medical course offered at some colleges, although some basic traditional Chinese medicine is also taught in the `western' medical courses. In the past doctors were assigned to particular specialties and hospitals but this now happens much less. Increasingly rural doctors have the chance to go for a year or more to a large city hospital for further training.
| OTOLARYNGOLOGY PRACTICE IN RURAL CHINA |
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Because of these difficulties—expense, lack of education, language barrier—patients tend to present late in the disease course. This is highlighted by the fact that the quietest times for the hospital are the sowing and harvesting seasons, when most of the population will be at their busiest. To spend time travelling to the hospital would mean a substantial loss of income, so patients endure the pain or other symptoms until the summer or winter months arrive.
The Liangshan Second People's Hospital attracts more of the poorer peasant farmer population than the First People's Hospital because its charges are lower. The patients seen are thus even less well educated and more impoverished. They often have to travel from villages far away to reach Xi Chang, sometimes on a small bus driven over uneven mountain roads. Patients generally selfpresent, but some are referred from local small town hospitals where facilities are inadequate.
The Second People's Hospital, with 370 beds, is staffed by doctors from the local health school or from universities within the province. Most specialties are represented, exceptions being cardiothoracic surgery and neurosurgery. The hospital managers are all doctors themselves, as are many of the office staff. They give up clinical practice to run the hospital. Much of the hospital's income comes from user fees, so all consultations, investigations and treatments are itemized. Separate payments must be made for inpatient and outpatient consultations, occupation of a bed, intravenous infusions, drugs, pathology services, radiological investigations, type of anaesthetic, operations and so on. Payment must be made and a receipt produced before the doctor will instigate treatment. Otolaryngology patients are charged a supplement to the basic consultation fee if they require indirect laryngoscopy and flexible or rigid nasendoscopy. If they cannot pay then a cheaper alternative must be found or they must do without; often they have to borrow money from relatives or friends. Otolaryngology operations under general anaesthesia can cost in the region of 1000-4000 renminbi (RMB) and some of the poorer peasants may earn less than RMB 1000 per year. For such people an operation is a major financial undertaking, to be undergone only if truly necessary. The expense could well place them below the official poverty line.
The hospital otolaryngology inpatient department is completely separate from the outpatient department with different doctors working in each. Most doctors will practise either outpatient or inpatient otolaryngology, not both. One doctor staffs the outpatient department, where minor operations can be done under local anaesthesia. The inpatient department has two senior doctors and four junior doctors, and a small branch hospital is staffed by one junior doctor who rotates annually with the other juniors. The working hours are Monday to Friday full day and Saturday half day, with a 3-hour lunch break. Junior doctors can spend a year or more undergoing further training at a larger centre such as Chengdu (the provincial capital) or Beijing.
In the larger cities of China, as in the UK, otolaryngology is a specialty in its own right. However, in the smaller cities and towns it is usually combined with ophthalmology in a specialty known as Wu Guan Ke, literally the `five senses specialty'. This is the case in Xi Chang and the doctors are therefore knowledgeable in both otolaryngology and ophthalmology—especially useful when complications of one specialty overlap into the other, as in acute sinusitis with orbital complications. Most of the doctors were assigned to this hospital and specialty and they will probably remain there for the duration of their working life. This prospect does not cause obvious dissatisfaction.
For self-reporting patients (the majority) the first question is which specialty to attend and the next is whether to go to the outpatient or inpatient department and pay the required fee. Factors affecting their decision will be cost and whether they wish to be seen by a particular doctor. They have some choice since outpatients are seen in the inpatient department as well as the outpatient department. Once they are seen by the otolaryngologist, investigations, drugs or other treatments are suggested and the patient must then decide whether the subsequent fee is affordable. If the patient is self-funding, time may be needed to gather enough money, or there may be some discussion with the doctor to find a cheaper solution. If the patient's drug costs are met by his or her work unit, a separate prescription form is used.
The daily inpatient routine consists of a morning handover by the doctors and nurses who were on at night. The doctors and nurses separate to do their own ward rounds. There is a specific Wu Guan Ke (otolaryngology) ward and overspill from other specialties is unusual. Outpatient treatment is preferred because of the lower costs so there is rarely a bed crisis. As well as medical duties, doctors do dressing changes, sterilize instruments used on the ward and restock shelves with drugs and charts. Nurses do the usual temperature, blood pressure and pulse observations, and put in butterfly needles for infusions. The patients' relatives bring in food and help with bathing and other activities of daily living. After the ward work is finished, new patients will be seen as and when they present to the hospital service. There is no queuing system: as patients arrive, they and their relatives just crowd around the doctor, waiting their turn, even if the doctor is in the middle of seeing another patient. Privacy is almost unheard of. Waiting patients look on with interest and may even offer advice; no one minds or complains.
Investigations such as skin allergen tests, pathology services, ultrasound, and computed tomography (CT) are available. There is no waiting list for these investigations; the patient just pays the required fee. A CT scan of the sinuses costs RMB280 and will be done within one or two hours after which the patient returns with the report to the doctor. There are no audiologists, however, so the otolaryngologist must perform any necessary audiograms in a small backroom without soundproofing.
The commonest otolaryngology diseases seen in Liangshan Second People's Hospital are chronic pharyngitis, chronic sinusitis, chronic secretory otitis media, cholesteatoma, rhinitis, nasal polyps and tinnitus. These are usually treated with a combination of western and Chinese medicines. No formal follow-up appointment is arranged. It is expected that a patient who is still symptomatic will return spontaneously. Therefore clinics are usually not excessively busy, with 15-20 patients being seen in a day. Smoking is increasing in China and with it the pattern of disease is changing. In otolaryngology this means an increase in the incidence of head and neck cancers which, when diagnosed in Xi Chang, are sent to Chengdu, a university centre, for further investigation and treatment. Nasopharyngeal carcinoma, not related to smoking, is likewise referred to Chengdu for radiotherapy, since there are no radiotherapy facilities in Xi Chang.
Cataract surgery is the most frequently performed operation in Wu Guan Ke. Of the otolaryngology operations the commonest are mastoid and sinus surgery including functional endoscopic sinus surgery (FESS). The practice of otolaryngology is geared towards learning high-technology operations such as FESS for which equipment has been purchased. Yet simpler operations such as grommet surgery and equipment for tympanometry and auriscopy are neglected. Although sinusitis is common, so too is glue ear. Cholesteatoma is not infrequent but there are no suitable operating microscopes or drills; surgery is performed under direct vision or with an ancient microscope. Bone nibblers, hammer and chisel are used but the local doctors are extremely skilled in these methods, facial nerve palsy and other complications being unusual. Most otolaryngology surgery is done without a scrub nurse and under local anaesthesia. A junior doctor will act as scrub nurse in preparing the instruments and assisting (Figure 2). The Chinese patients, including the children, are remarkably stoical and will undergo operations under local anaesthesia that in the UK would require general anaesthesia. There are two main reasons for the common use of local anaesthesia. First is the cost. The patient having a general anaesthetic must pay for the anaesthetist, drugs and equipment used. The intensive care bed used for the anaesthetic recovery period is expensive and there is a longer inpatient stay to be added to the cost of the surgical operation itself. The second reason is that there is still a fear of `not waking up' from general anaesthesia, especially among the less well educated. The exception is surgery on very young children, where a general anaesthetic is given if the child will have difficulty staying still for long enough. If it is a short outpatient procedure the child may be held down while, for instance, an abscess is incised. After surgery the patient must walk back to the ward or be carried by relatives; there are no porters, wheelchairs or lifts between floors.
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Breaking bad news and patient confidentiality reveals another difference in the practice of medicine in rural China from that in the UK. For instance if a head and neck cancer is diagnosed, the custom is not to inform the patient but the relatives. It is up to them whether to tell the patient, and they usually do not. The reasoning behind this is the fear that the patient will give up. In particular, those less well educated tend to believe that, once cancer is diagnosed, death is inevitable. It often follows that they will not wish to `waste' their family's money on any treatment. If curative treatment is considered the patient will commonly be told it is for a benign disease. If the condition is incurable the relatives are advised to take the patient home to enjoy the rest of his or her life. During my time in Sichuan there were several patients with head and neck cancers who felt it useless spending money to be referred to a larger centre, despite a possibility of cure.
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