The following is an article published in the internationally renowned academic journal "The Lancet"
Chinese doctors are under threat
Editorial, The Lancet, Vol 376, 9742, 657; 28 August 2010-3 September 2010
Editorial, The Lancet, Volume 376, Issue 9742, Page 657, August 28-September 3, 2010
System change, the theme of the World Cancer Congress in Shenzhen, China, Aug 18–21, was a central message in the opening address by the Chinese Minister of Health, Chen Zhu, as he described current health-care system reforms in China. At the Congress many international health policy makers and physicians led discussions on frameworks and actions for system change, but there was little participation from local Chinese doctors.
System reform is the theme of the World Anti-Cancer Conference held in Shenzhen, China from August 18 to 21. It is also the main content of China's current medical and health system reform in the opening speech by China's Minister of Health Chen Zhu. Many international health policy makers and doctors participated in the discussion on the structure and implementation of the system reform, but no local Chinese doctors participated in the discussion.
To understand why there were so few Chinese delegates in the plenary sessions on system change compared with sessions on patients’ care, one must first understand that for many Chinese doctors personal safety is of greater concern. Chinese doctors are often victims of terrible violence.
Compared with the number of people attending the patient diagnosis and treatment branch, why are so few Chinese representatives participating in the system reform plenary meeting? To understand this problem, you must first understand that many Chinese doctors are more concerned about their own safety issues. Chinese doctors are often victims of terrorist violence.
In June this year, a doctor and a nurse were fatally stabbed in Shandong Province by the son of a patient who died of liver cancer 13 years ago, and a paediatrician in Fujian Province was injured after leaping out of a fifth-floor window to escape the angry relatives of a newborn baby who had died under his care. Thus, it is not surprising to see that in July police officers were invited to be the vice-presidents of 27 hospitals in Shenyang. With hospitals turned into battlegrounds, being a doctor has become a dangerous job in China.
In June of this year, a doctor and a nurse in Shandong Province were fatally stabbed by the son of a patient who died of liver cancer 13 years ago. A pediatrician in Fujian Province tried to avoid the angry relatives of his deceased newborn. , Jumped from the 5th floor window and was injured. Therefore, it is not surprising that in July 27 hospitals in Shenyang hired police officers to serve as deputy deans. With the hospital becoming a battlefield, being a doctor in China has become a dangerous profession.
The problem may be largely one of perception. Many Chinese patients believe that doctors and hospitals conspire to increase charges by providing unnecessary examinations, investigations, and treatments. Additionally, some doctors accept red envelopes (a monetary gift in exchange for favourable service) against the rules. Many patients blame the deterioration of their health directly on doctors, claiming that doctors lack devotion and skills. The intellectual ideals of ancient China were “either to be a good prime minister or to be an excellent doctor”, while in modern China doctors and nurses used to be worshipped as “angels in white”. How has the perception of Chinese doctors become so eroded?
This problem may be mainly a problem of ideas. Many Chinese patients believe that doctors and hospitals are conspiring to increase fees by providing unnecessary examinations, tests, and treatments. In addition, some doctors illegally accept red packets (cash gifts in exchange for favorable services). Many patients directly blame their doctors for their health deterioration and assert that doctors lack professionalism and professional skills. The ideal of the intellectuals in ancient China was "not to be a good doctor, but to be a good doctor", while modern Chinese doctors and nurses were once revered as "white angels." Why has the image of Chinese doctors become so bad today?
The Chinese media certainly have an important role in provoking tension between doctors and patients. There is disproportionate coverage in newspapers, television, and on the internet of how health professionals have cheated patients. Just a few weeks ago the Southern Metropolis Daily (the most popular newspaper in Guangdong) falsely accused a midwife, who had treated haemorrhoids for a patient after childbirth, of stitching the patient's anus closed on purpose. In November,2009, one of China’s most authoritative media outlets, CCTV (China Central Television), reported that the renowned Peking University First Hospital was carrying out illegal medical practices by allowing medical students to do surgical procedures, and as a result a patient had died.
The Chinese media undoubtedly played an important role in intensifying the tension between doctors and patients. Newspapers, television, and the Internet over-reported how health professionals deceive patients. Just a few weeks ago, "Southern Metropolis Daily" (the most popular newspaper in Guangdong) falsely accused a midwife of deliberately closing the patient's anus while treating hemorrhoids for a postpartum patient. In November 2009, one of China's most authoritative media, CCTV (China Central Television) reported that the famous Peking University First Hospital illegally practiced medicine and allowed medical students to perform surgical operations, which resulted in the death of a patient.
Even though the hospital and the Ministry of Health made it clear that involving medical students in clinical procedures including surgery under the supervision of licensed doctors is legal, trust in doctors and hospital was seriously damaged. It is hard to tell whether the misreport resulted from a lack of medical knowledge on the parts of the Southern Metropolis Daily and CCTV, or whether it was motivated by a desire for a sensational story. However, the public misunderstanding of the medical profession will surely hurt both doctors and patients in the end.
Although the hospital and the Ministry of Health have clarified that it is legal for medical students to participate in clinical work including surgical operations under the guidance of qualified doctors, the reputation of doctors and hospitals has been severely damaged. It is difficult to say whether the reason for the above false report is the lack of medical knowledge in Southern Metropolis Daily and CCTV, or the deliberate pursuit of sensational stories. In any case, the public’s misunderstanding of the medical profession must ultimately hurt both the doctor and the patient.
Most hospitals in China, especially the large ones such as Peking Union Medical College Hospital and Huashan Hospital of Fudan University, are run by the government. Public hospitals in China enjoyed full government funding before 1985. After economic reforms, the hospitals now receive very limited financial support from the government,with the result that hospitals must generate income to cover costs. As the main source of hospitals’ income is from diagnostics and treatment, there is a financial incentive to over- investigate and over-treat.
Most hospitals in China, especially large hospitals such as Peking Union Medical College Hospital and Fudan University Huashan Hospital, are managed by the government. Before 1985, public hospitals in China enjoyed full government funding. Since the economic reforms, the hospitals now receive very limited government financial support. As a result, the hospitals must engage in revenue generation to compensate for the costs. Because the main source of hospital income is diagnosis and treatment, the resulting income-generating incentive policies have resulted in over-examination and over-treatment.
To minimise inappropriate conflicts of interest, the Chinese Government passed laws to prevent doctors receiving financial kickbacks from drug companies. Because the standard salary of a doctor is modest, even by Chinese standards, many doctors struggle to balance professional ethics and making ends meet in an economically booming China. Such pressures, coupled with a sense of feeling seriously undervalued by the government and society as a whole, drive many doctors out of medicine into other jobs.
To avoid inappropriate conflicts of interest, the Chinese government passed laws to prevent doctors from accepting financial rebates from pharmaceutical companies. As the benchmark salary level of Chinese doctors is a bit low even according to China's standards, many Chinese doctors strive to weigh professional ethics and maintain breakeven in the environment of rapid economic development in China. This pressure, coupled with the feeling that their own value is seriously underestimated by the government and society at large, has prompted many doctors to switch to other professions.
China’s health-system reforms cannot be successful without reforming the social and economic status of doctors. Chinese doctors should be involved more in shaping health policy, by giving voice to their own experiences and constructive ideas about the health system.
Without improving the social and economic status of doctors, China's medical and health system reform will not succeed. Chinese doctors should be more involved in the formulation of health policies, speaking and making constructive opinions on the medical and health system based on their own experiences.