A Tale of Two Systems

Dear Editor:

I read with great interest the excellent editorial by Congdon and Aung entitled, “A tale of two systems: health reform in China and the United States.”¹ The authors commented meaningfully on the bloated charts that slowed down the ability to provide needed cataract extractions for patients in China. Missing from their commentary, however, was a mention that similar phenomena increase expenses and diminish patients' access to care in the United States.

Virtually every American ambulatory surgical center requires a moderately extensive preoperative testing, including electrocardiograms. This is the case despite evidence that testing does not increase the safety of surgery. In a review by Keay et al, the authors concluded, “This review has shown that routine preoperative testing does not increase the safety of cataract surgery.”² A related conclusion was reached by Sweitzer³ who pointed out that even in cardiology, history taking provides almost all of the needed information, and that chest radiographs and electrocardiograms provided new information in only 3% of diagnoses.

The point? There is a risk in doing something. There is also a risk in not doing something. Care can be made so “safe” that it becomes prohibitively expensive, meaning that care often does not get rendered. There is at present a disturbing hypocrisy. Many treatments are promoted as “safe.” Yet “safe” does not mean they are free from complications. The implication is always that they are “adequately safe.”

There are major differences between regulations designed to protect the subjects of an action and, on the other hand, regulations designed to protect those acting, in this case physicians and medical institutions such as hospitals. Practices designed to avoid virtually all risk raise costs for everybody, sometimes to an extent that those needing care cannot afford it. Is this really “safe?”

It may be prudent to evaluate some of our routine practices, such as sedating patients for minor, or even major, procedures and testing them extensively to try to avoid every conceivable complication. There may be a better balance than presently characterizes many hospitals. In Ethiopia, for example, patients come to the operating area, put on a gown over their clothes, walk into the operating room, lie down on the operating table, have topical or injection anesthesia, have their surgery, stand up, walk out into the adjoining room, take off their gown, and go home. Patients rarely receive any sedation of any kind. A review of the surgical results of one hospital practicing in this manner found no evidence that complications were higher than those in American surgical centers.

As pointed out by Congdon and Aung, as the world's population ages, the number of people needing ophthalmic surgery increases. We can make “safety” so absolute that a major portion of those individuals do not get surgery. Does the possible benefit of stringent regulations warrant the definite risk of less care?