My wife has excellent local health insurance which covers an annual physical, so we’ve been going to one of China’s more famous physical exam centers, called Ciming Health Checkup. This apparently large chain has clinics all over China with one goal in mind — to do physical exams. Sort of.

It’s not a hospital, it’s a large office-style building with doctors and nurses — but most importantly, a slew of fancy equipment. You can customize your exam, and for a few thousand RMB you can get routine blood tests plus a whole lot more:

• Cancer enzyme screening
• H pylori breath test
• Chinese medicine exam by TCM doctor (Rx extra if needed, as everyone has some type of excess/deficiency imbalance)
• Ultrasound of everything important: abdomen, carotids, heart, prostate/uterus
• CT scans and x-rays

You can also get some fancy things like a transcranial doppler exam looking for atherosclerosis in your brain’s blood vessels. The most fun I had was their full body thermal scan — which I’ve never even heard about in medical school — which involves standing almost naked in front of a heat detector which looks for abnormal signals. This most recent time I also tried a “Quantum FAFA bio-energy screening tracing system”, which prints out a detailed analysis of dozens of risk factors and nutrition status — all from analyzing your palm on a scanner.

During this 2-hour time, I went from room to room in my hospital pajamas, escorted by nurses, and occasionally given tea and snacks. After all the tests are processed in a couple days, the data is printed out and reviewed with a doctor at followup (in Chinese). The facility is quite modern and clean, and the overall experience was very professional. But…

But?

Yes, here’s the problem for me: after 2 hours from test to test, not once, ever, did any doctor ask me anything about my previous medical history. Never was I asked about current medicines, current complaints, allergies, family history, or surgical history. And no one ever took a stethoscope to listen to my heart and lungs, or looked at my skin for scary moles, or palpated my abdomen for masses.

That really bothers me. It bothers me because every good doctor knows that 80-90% of all diagnosis is from the history and physical only. Tests are mostly used to confirm or deny a diagnosis. So, any health care facility that relies 100% on tests, without even asking the patient one question about their health history, is clearly not providing efficient or effective health care. Of course, Ciming is not a clinic or hospital and does not treat people, it simply performs screening tests and physical exams. Screening tests that are done at Ciming and your routine health checkups have a unique goal to pick up disease at early stages, before you have any symptoms to complain about. Many screening tests do work well and save many lives, like blood pressure checks, glucose checks for sugar, pap smears, and mammograms after 50 years old. The big problem with the majority of the tests at places like Ciming is that there is very little evidence that they save lives. Yes, occasionally some test may have a concerning result, and followup may discover something dangerous. But the vast majority of abnormal results found on their cancer enzymes, CTs, ultrasounds and thermal scans would find incidentalomas — benign lumps that will scare the patient into costly and invasive exploratory tests which usually find nothing serious.

Also, screening tests themselves can cause problems — a person getting an annual CT scan to check for cancer is not only falsely reassured by a normal test, but also dramatically increases his risk of getting a cancer due to the high radiation in an annual CT. This is exactly why the recent wave of Screening CT Centers in the U.S. has rapidly declined as a business.

The end result for China is that massive amounts of precious healthcare dollars are being spent on screening tests that in most countries are not recommended due to lack of evidence or a poor cost/benefit ratio.

Where’s The Primary Doc?

I think one of the big problems for China’s healthcare is that there still is no system or culture of primary care. Very few in China have a “family doc” that the entire family has seen for years, who follows their risk factors and orders appropriate screening tests. So, in the absence of such a system, people are resorting to the next best option — a physical exam via these private or public centers. But again, there’s no continuity of care for follow-up or management.

And where’s the emphasis on preventive medicine at all? Where’s the doctor taking your social history and finding out that you’ve smoked a pack a day for 20 years and drink every night, and perhaps you should tackle those issues before you simply repeat your annual chest CT and think you’re fine?

These Ciming exam factories are simply reinforcing the prevalent Chinese notion that tests and procedures are always beneficial, and more is always better. I am told that many Chinese hospitals have similar VIP-type physical exam wards where people stay literally for days and get multiple tests done as part of a VIP Premium Physical. Who wins in the end here? Sure, this is all private money and no one is forcing you to go. And perhaps the local hospitals take that extra profit to cover their budgets better and provide better service to the more needy. But I’m concerned more for the bigger picture here, that all the newly wealthy Chinese are thinking that this type of exam is what you do for good health. Why isn’t there a massive private industry push for decent primary care clinics staffed with family doctors?

What about the expat clinics? Do we do better?

I don’t disparage the concept of comprehensive screening, I only expect the offerings to be evidence-based. All of the Beijing expat clinics, including mine at BJU, offer various levels of comprehensive physicals. I do think that all of these clinic-based exams would be better than at private places like Ciming for a couple reasons;

• #1 You can develop a long-term relationship with a GP who can deal with any followup issues.
• #2 We would take a comprehensive history and hands-on physical exam (far more important than almost any screening test)
• #3 We offer more evidence-based screening tests (no thermal scans, palm reading…)

Hopefully, as China’s healthcare evolves, the country will soon be fully covered with modern outpatient clinics and well-trained primary care doctors — using both private and public money. Only then will all levels of society get the comprehensive, preventive care and advice they deserve.