Sunday, 15 May 2016

Putian hospital surgeon spills the beans on dodgy practices


Dr Qiu Jianqin is a plastic surgeon turned cosmetic surgeon from Fujian province who has a few unkind things to say about Putian hospitals. In an 'exposure' aired in the Chinese media this week, Dr Qiu talks of his four years working in a Xiamen hospital run by the Putian network - and portrays it as rife with corrupt practices, overcharging, health insurance fraud and substandard clinical practices.

Before I describe these in more detail I should point out that Dr Qiu may well be an aggrieved ex-employee because he has been sacked by the hospital over claims that he was treating patients privately, in an unauthorised way, in his own premises. Dr Qiu and the hospital are now in litigation over unpaid wages, broken contracts etc etc.

The expose comes from the Southern Weekend - based in Guangzhou, which has a reputation for relatively bold investigative journalism.

Dr Qiu says he made the move to the Xiamen New Century hospital in 2011 after becoming burnt out and disillusioned working in the public hospital system. Despite being a senior plastic surgeon, (he is a representative of the Chinese Medical Association Standing Committee of Fujian plastic and cosmetic branch) Dr Qiu says his workload was excessive and the rewards small. The market reforms in the public sector meant that many burns units became more oriented towards lucrative cosmetic surgery, and gave staff commissions and quotas to generate more income for the hospital. And yet at the same time, the hospital still had an iron rice bowl mentality in which they were overstaffed by bureaucrats, says Dr Qiu. The last straw was when his assistant surgeon left over low pay, and Dr Qiu allowed himself to be lured by the promise of the New Century Hospital. He was personally invited by the manager, Su Qincan, who he said spouted a lot of hype but promised a lot of benefits and good facilities.

Su Qincan
Dr Qiu joined the New Century Hospital along with his wife, a senior nurse, but was disappointed to find that the private facility was lacking in many basic facilities such as as resuscitation equipment that are standard in public hospitals.  He wasn't aware initially that it was part of the Putian network, and he had a poor impression of that group. His negative impressions were confirmed when he found that the hospital was now what it purported to be. While claiming to have many different departments, it actually concentrated only on four areas: cosmetic medicine, STDs, obstetrics and dentistry. The other departments - required by health department regulations were 'Potemkin villages' - they were there in name only and were only staffed when health department inspectors visited, at which time they 'borrowed' clinical staff from sister hospitals. The New Century even paid 10,000-30,000 RMB to 'rent' the name plaques of several senior doctors, to make it appear as if they had many eminent consultant physicians and surgeons.

Dr Qiu found that the doctors and managers working at the hospital were unscrupulous profiteers. They would lure in patients, overdiagnose and overtreat their illnesses. In the cosmetic filed, a simple skin fold operation that would typically cost 50 RMB in a public hospital was being billed at 1000 RMB at New Century. If patients complained about costs or about botched procedures the hospital's policy was to engage them with obstructive and expensive legal actions.

The hospital also engaged in routine health insurance fraud - doing extensive cosmetic work such as liposuction and claiming it as appendix removal was one  common example. The hospital accountants became skilled at 'swiping' the health insurance cards of patients, using all their family credit balance on the card even if just one person was being treated at the hospital.

Dr Qiu said this practice was so widespread that the local health authorities must have known but they were also bribed by the hospital. The hospital managers had a well organised system of what Dr Qiu termed "Feeding Putian Cake" - taking officials out to dinner on a monthly basis and allowing them to win 'prizes' of department store spending vouchers worth 1000RMB.

Dr Qiu said that at first he believed this widespread corruption and malpractice was a passing phases as part of the transition to a market-based healthcare system - and he believed he could help improve standards and bring change from within. However, after a couple of years he realised things were getting worse, not better and he started to look for ways out of his five year contract. He was working on commission and described it as being "like forced prostitute"

His managers told his he could not leave and warned him that he would not be able to work anywhere else because his name would be blacklisted if he broke his contract. Things came to a head in 2015 when Dr Qiu kept making complaints and demands for improvements in the hospital. He was told he had been fired - along with his wife. The given reason for his sacking was that he was 'sneaking work home' - seeing patients privately without payment through the hospital. Dr Qiu disputes this. And now he has entered into a litigation with the Putian hospital and its manager Su over unpaid wages and the refusal to hand over his documents and medical licence.

Sunday, 8 May 2016

After the vaccine scandal, now a cancer treatment scandal

Wei Zexi's parents

For someone ostensibly responsible for healthcare, China's health minister Li Bin is keeping a very low profile throughout a string of healthcare scandals. She was invisible during the recent scandal over 2 million doses of out-of-date vaccines that were widely distributed by dodgy wholesalers. Now she is also missing in action during the national uproar over the death of a 21-year old cancer patient Wei Zexi, who was duped into having an expensive and unproven cancer treatment at Beijing's Armed Police Corps Second Hospital.

As has already been widely reported, the hapless Wei found the hospital through its paid search results coming top in the search engine Baidu. Much of the commentary so far has been around the responsibility (or lack thereof) of Baidu and its dependence on shonky medical clinics for much of its paid search advertising revenue. There has also been a lot of adverse commentary about the role of the Putian network of private hospitals. As has been mentioned several times before on this blog, the Putian 'network' is a loose association of entrepreneurial clinics and hospitals offering healthcare services on the fringe of mainstream medicine - they specialise in 'monetiseable' services such as cosmetic surgery and fertility clinics. It therefore comes as little surprise to find they are implicated in the latest scandal.

With a synovial sarcoma, Wei Zexi is said to have paid 200,000 RMB (about US$30,000) for a novel "biological immunotherapy" treatment from the Putian-affiliated oncology unit at the Beijing Armed Police Corps Second Hospital. As a medical journalist who has been reporting on oncology for more than a decade I have to say I had never heard of the so called "DC-CIK immunotherapy" offered by the hospital. I did a bit of googling (not Baidu-ing) and looking through the peer-reviewed literature, and it soon became apparent that this is an experimental therapy that sounds impressively technical but has virtually no evidence or clinical trials to support its use.

The Beijing clinic claimed that the DC-CIK technique had been invented by Stanford university in California, but it didn't take Chinese reporters long to discover that the procedure is not being used at many reputable hospitals or institution in the US. A phone call to the developer of the technique at Stanford revealed that it is being used as an adjunctive (back up) treatment for some rare kinds of myeloproliferative diseases, but it is not a mainstream therapy. DC-CIK has also been reported in the Chinese/Hong Kong media as being used as a pseudoscientific and discredited cosmetic treatment.

So what is DC-CIK immunotherapy? It stands for "Dendritic Cells and Cytokine-Induced Killer" cell immunotherapy. Dendritic cells (DC) are basically part of the body's defence system against tumour cells - they present the antigen and activate the defensive T lymphocytes that kill tumor cells. Cytokine-induced killer cells (CIK),are the body's way of killing tumour cells - but they are non specific and need guidance to recognise the tumour cell as different from a healthy cells. In theory the coupling of these two systems should create the perfect tumour fighting team. But in practice... well, look at the fate of poor Wei Zexi. There have been no clinical trials of DC-CIK, so its use is essentially just guesswork.

Putian affiliate Chen Xinxian
Meanwhile back in the murky world of Putian clinics the journalists at Caixin have been doing some detective work and found that the dodgy hospital that milked Wei Zexi out of $30,000 for a useless pseudoscientific treatment is linked to a well known Putian duo called Chen Xinxian and Chen Xinxi and their company Shanghai Kangxin Hospital Investment Inc. Matching up business and internet records, Caixin found that the Chen brothers were involved in the running of 134 military hospitals around China. The PLA has basically subcontracted out its clinics to the Chen company

Caixin went further and tracked down about 20 other hospitals that are offering the DC-CIK procedure. When contacted by Caixin, many of the hospitals denied it or refused to comment, but Caixin found evidence that they were offering DC-CIK in the form of adverts and recruitment ads that sought staff to offer the treatment.

We thus have a situation in which many Chinese hospitals are exploiting cancer patients by charging them hundreds of thousands of RMB for unproven and dangerous treatments. Many of these hospitals are linked to the military and are thus out of the usual health department jurisdiction. It's notable, then, that this week has seen the Chinese central government declaring that the PLA will have to completely divest itself of commercial ventures such as its hospitals.

In the meantime, it's worth asking how - within a month of the vaccine scandal - China again find itself with having to address a major and widespread breakdown in the quality of its healthcare services. In a developed society such as Australia or Hong Kong, shonky medical practices are kept at bay by a series of checks and balances. Why would the DC-CIK scandal not have panned out in these societies?

1. If a clinic in Sydney or Hong Kong started advertising and offering DC-CIK to cancer patients, it would quickly come to the attention of the media, possibly by whistleblowers. Lack of press freedom in China - and fear of retribution against whistleblowers - means that this check is weak or missing.

2. Medical practitioners in developed countries also face scrutiny from their peers in the form of medical boards and general 'collegiate' links that make it clear what is accepted practice and what is not. An oncologist in Hong Kong or Sydney would be guided by professional guidelines on 'best practice' - and the use of DC-CIK would certainly not be construed as acceptable practice by a reasonable practitioner. The doctor would first warned by his peers and then brought before the medical board and struck off if he/she offered shonky treatments such as DC-CIK. This is obviously not happening in China, despite reports that the clinicians offering DC-CIK are retired or part time senior doctors.

3. There is obviously a problem with clinical governance in China - it is not identifying and addressing bad practice. In developed countries, bad doctors are also kept at bay by a mix of accreditation - having to meet defined professional standards - and also the threat of medicolegal action. This basically means that a doctor or clinic in Sydney or Hong Kong that offered a dodgy treatment like DC-CIK would have its ass sued off - and face a big compensation payout. But in China the jails are now full of lawyers who made the mistake of standing up for the rule of law.

4. And of course dodgy medical therapies are also kept at bay by advertising standards. If Google or a media outlet pushed a dodgy treatment like DC-CIK they would be prosecuted and fined for  deceptive advertising - or for promoting therapeutic claims that are not backed up by evidence. In China, however, Baidu is quick to censor words such as Dalai Lama, but is is given official blessing to rake in millions from advertising dodgy Putian clinics.

One final comment on the whole Wei Zexi/Putian/Baidu saga: it's worth noting that the President Xi Jinping is a former governor of Fujian and has close links to the region that includes Putian. He has gone on record as saying he considers the area his second home. Do the dodgy operators of Putian hospitals gain some degree of patronage and protection from their former provincial boss?

UPDATE: 14/5/2016

A search of PubMed shows there are virtually no clinical trials of DC-CIK published in major peer reviewed journals outside of China. Virtually all the studies are from Chinese centres and they are published in obscure Chinese-language publications. That's not to say there aren't any studies worth looking at. However, even one of the most reputable studies I was able to find showed only  a minimal effect of DC-CIK on cancer outcomes: in a two year study in lung cancer patients, the mortality difference at two years was 5%. In other words only one in 20 patients would still be alive as a result of treatment after two years. Put another way, for every 100 patients treated with DC-CIK, after two years 75 would be alive, whereas 70 would be alive if they received standard chemotherapy. Did the doctors treating Wei Zexi tell him that 19/20 patients would get no benefit for their 300,000 RMB?

Monday, 2 May 2016

A tale of medical murder and extortion

It sounds like the plot of a TV detective thriller but this is real life. A 41-year old man is brought by a friend into a Chengdu hospital suffering from diarrhoea. They both appear to be respectable middle class citizens. The illness is not serious, and the man is treated in the usual way for acute gastroenteritis. He is given intravenous antibiotics including clindamycin, and usually his symptoms would be expected to resolve within 24 hours. 

However, an hour after the antibiotics have been given, the man loses consciousness, turns blue and dies. All attempts to resuscitate him by hospital staff fail. He appears to have died from cardiac arrest. The victim's companion becomes indignant, agitated and blames the hospital staff for negligence. He says the clindamycin may have triggered the cardiac arrest and should not have been used. He demands compensation otherwise he will commence an expensive lawsuit against the hospital for damages.

At this point some of the medical staff find something suspicious about the behaviour of the 'respectable' man, his certain knowledge knowledge of clindamycin's rare side effects, and advise that the body undergo an autopsy. The victim's friend becomes more agitated at this suggestion, but the body is taken away for examination.

A detailed physical examination reveals a small puncture in the back of the victim's left hand. This was the intravenous line where a catheter had been inserted to give the antibiotics. To rule out the possibility that a nurse had given the wrong drug, the pathologist orders tests run on the victim's blood sample, and these come back with surprising results. The victim appears to have been sedated and anaesthetised, because the blood contains high levels of propofol - the anesthetic that killed Michael Jackson. It also contains the sedative midazolam and the muscle relaxant vercuronium. Combined, these three drugs would be sufficient to cause rapid respiratory failure and cardiac arrest. That's why they are used to execute prisoners in the US.

The victim's friend was apprehended and questioned by police and the true story emerged.
He confessed to secretly added mannitol - a liquid laxative - to the victim's drink, which caused diarrhea. Next, the man brought his apparently sick friend to the hospital for treatment. When the victim fell asleep and no other people were present, the man injected 10 mg of midazolam into the victim's vein through the path established for fluid infusion. Next, the companion twice injected 200 mg of propofol and 4 mg of vecuronium into the victim's vein. A few minutes later, the victim's breath and heartbeat stopped.

The perpetrator was revealed a surgeon with four years' experience who had gained access to the drugs from a former colleague at the hospital. He would have got away with the crime - and perhaps received a large sum in compensation if his behaviour had not raised suspicions of the vigilant medical staff.

This case is reported in the Journal of Forensic Sciences by Dr Ye Yi and colleagues of the Department of Forensic Analytical Toxicology, West China School of Basic Science and Forensic Medicine, Sichuan University, Chengdu. The fate of the perpetrator is not given, but it can be presumed he was tried for homicide - and if found guilty, received the death penalty.