It would seem a perfect match. There’s tech-crazy, robotics-loving China; a country that is investing trillions of US$ to bring its healthcare system closer to those of the most advanced nations and has thousands of industry robots in place — 68,000 robots were installed in 2015 alone, more than in all European countries combined. Then there are “surgical robots,” one of the highest of high-tech medical innovations. What’s to keep China and surgical robots apart?
A few things, it turns out. To be sure, China’s hospitals are experimenting with the technology: 57 surgical robots are now used at 50 Chinese hospitals to manage over 100 diseases. Dr. Chi-Fai Ng, a urologist at the Chinese University of Hong Kong, says that the Chinese government now requires every province to install at least one of the machines. Meanwhile, patients are eager to have the latest and greatest in treatment.
But compared to Japan, which has 183 installed surgical robots, and the U.S. with 2,200, China is moving slowly. Among the reasons: The costs of the systems are a strain on Chinese healthcare system budgets that have to address a multitude of more basic healthcare-system needs. Surgeons don’t have the time or opportunity to pick up the extensive training needed. And the relative efficiency of robot surgery doesn’t necessarily justify patient enthusiasm.
Still, Chinese surgery patients are often more enthusiastic about the robotic option than their doctors, says Yao Li, a Chinese scientist specializing in medical robotics who is currently a visiting scientist at Stanford University’s Robotics Laboratory. “Although the advantages of robotic surgery are still under debate between surgeons and patients, more and more patients are willing to try the robotic system if they have the option and resources,” he says. Many patients simply won’t take no if the option for using a surgical robot is available. Nobuhiko Hata, a radiologist and Director of the Surgical Navigation and Robotics Laboratory at Harvard Medical School, says that “patients in China have a lot more authority and say in the kind of care they receive compared to patients across the U.S. They can demand the physician give them the medicines and treatments they want.”
Hata says that part of the appeal of robotic surgery lies with the fact that it provides the most minimally invasive surgery available, which means smaller scars for many kinds of surgery. Because many Chinese patients — as well as many of the patients from elsewhere in Asia who travel to China for procedures — are highly body-conscious, Hata says, they gravitate toward robotic surgery for cosmetic reasons. That’s especially true for affluent Chinese patients who are willing and able to pay out of pocket if their medical insurance won’t cover all the extra costs of robotic surgery. “In China, this is seen as a posh, advanced new treatment,” Hata says. That’s part of the reason patient demand for robotic surgery is greater than it is in the U.S.
Because of this demand, robotic surgery is employed in a wider range of procedures in China than in the U.S., says Dr. Yong Zeng, vice dean of Sichuan University’s West China Hospital, and a liver surgery and transplant specialist. In the U.S., surgical robots tend to be employed in urology, gynecology and cardiac surgery, he says, whereas in China they are also commonly used for gastrointestinal, liver and pancreas operations.
If many physicians in China are less excited about robotic surgery than some of their patients, they have good reason, starting with a lack of clear evidence that robots lead to better results. “There is no main difference regarding the primary outcomes of robotic surgery compared with minimally invasive surgery in China,” says Zeng. “The most significant differences reported were longer operating times and lower blood loss with robotic system, but the principle factors, such as the number of lymph nodes harvested, surgical complications or days stayed in ICU, were reported as no different.”
Some Chinese hospitals are balking at the costs of the systems — about US$1.5 million apiece. In addition, the Chinese government, which provides most health insurance, isn’t eager to cover the costs of robotic procedures. “Due to the high costs of the technology, supporting supplies and the cost of training doctors, robotic surgery is five to six times as expensive as traditional laparoscopic surgery,” says Stanford’s Li. “In the U.S. market, health insurance covers most of the cost for robotic surgery. But patients in China are responsible for 100 percent of the expense and there is no commercial insurance currently available to cover the costs.”
Adding to the challenges of adopting robotic surgery is the fact that Chinese surgeons tend to be overworked and underpaid compared to their counterparts in the U.S. and other advanced countries, says Max Q.-H. Meng, professor and chairman at The Chinese University of Hong Kong. “Surgeons in China are under pressure to do more surgeries,” he says, which isn’t compatible with the slower, more painstaking work required in robotic surgery.
Those Chinese surgeons in a position to do robotic surgery generally have to come to the U.S. for training, says Dr. Jay Redan, medical director of minimally invasive general surgery at Florida Hospital Celebration Health, and a robotic surgery specialist who frequently provides that training. Surgeon training obviously takes time and money, he notes, but then you still have to train operating-room nurses and staff how to use the equipment, too. “If one link in that chain is broken, you’re not going to be able to use the system,” Redan says.
These costs may end up driving robotic surgery in China toward the country’s military hospitals, says Redan, noting that the Chinese military recently purchased 34 surgical robots. Military hospitals typically have bigger budgets than other hospitals, and can compete with them for civilian patients.
On the other hand, military hospitals aren’t as closely regulated as other hospitals. That means that some patients may have to choose between having the robotic option for their procedures and their overall safety. Sometimes pursuing the leading edge — and tiny scars — has its drawbacks.
— Jacqueline DiChiara
Jacqueline DiChiara is a freelance writer based in Boston, Massachusetts.