Reported by Xiaohan Liu
Another doctor was stabbed by her patient at noon on 19 March 2020, at the time she was preparing for the patient’s dialysis. This is the third reported violence incident against doctors within a year in China.
Soon, the department head of ophthalmology in Beijing Chaoyang hospital, Tao Yong, who is the victim of the second incident, reposted the piece of news on his social media account and prayed for the safety of the young female doctor. Before Tao Yong, doctor Yang Wen, who worked in a hospital in Beijing, was murdered by her patient’s son while working at the office.
The National Health Commission of the People’s Republic of China condemned the vicious crime as a criminal offense but not merely a normal doctor-patient dispute.
Violence against health workers has always been a nightmare in China. From 2000 to 2015, cases that patients assault medical workers show an increasing trend overall. Medical workers who are assaulted to death are also worth to be noticed.
The string of attacks on the medical staff, especially on doctors, cause
a wave of outpouring anger among the public. On 28 December 2019,
China’s first fundamental and comprehensive law on basic medical and health
care services was approved by the Standing Committee of the National People’s
Congress. The proposed law would be executed from June 1st, 2020. It emphasizes
that the whole society should make every effort to protect the medical
staff from violent attacks and anyone who breaks the law would receive
Villion, who is a lawyer, explains that the new law mainly serves as a deterrent, as there are no differences in sentencing before and after the execution of the law.
Another lawyer, Wang Dong Mei, who is a member of the NPC as well, explains that “the violent behaviors against physicians and nurses are definitely criminal cases. The criminal law is used widely in these cases as an after-event penalty. But what urgently needed is the law and regulation for beforehand prevention. That's the effect of this new set of regulations.”
On March 26, 2020, a new regulation of the security management in hospitals in Beijing was submitted to the Standing Committee of the NPC for hearing. The regulation rules that all the hospitals in Beijing should set police rooms to protect the safety of medical staff. At the same time, it specifies behaviors that are prohibited in hospitals, like assaulting medical personnel and carrying knives and flammable and explosive materials. Thus the regulation can protect the safety of the medical staff on an institutional level.
“Reflective measures that have been taken in Beijing are influential for the whole country since it is the political and economic center of China,” said Wang.
Pudding, a medical supervisor who works for a medical company, shows his negative attitude toward the targeting legislation. He thinks the point is the enforcement of the law, but not the legislation. “Taking drunk driving as an example, everyone knows it’s illegal, but only after the drunk drivers are arrested strictly, people begin to attach importance to it.”
For Mrs. Mu, the mother of an 8-year-old girl, her thoughts are different from doctors. Shen thinks for patients and their families, sometimes they are vulnerable groups compared to doctors and other medical staff in some cases.
She told about the experience of her daughter who has been taken to a hospital in Zhejiang Province after feeling collywobbles for a long period. “I didn’t mean to find fault, but I was really annoyed by what the doctor did at that time,” said Mrs. Mu.
Facing the tough and emergency situation, anxious parents chose to register a relatively more expensive specialist to prove the accuracy of diagnosis. Their daughter was diagnosed with a kind of stomach disease.
After two weeks of observation and taking medicine, the girl did not take a turn for the better, so the parents took the girl to the other doctor, Chen, to check. But Chen refused to add a quota contemporarily for the girl despite she was her patient. At the same time, she agreed to add a quota for the other patients. In addition, the doctor rebuffed the demand of parents that she would explain the reason for the symptom.
Mrs. Mu was enraged by the situation and complained to the relative bureau of the hospital. However, her complaint received no response. The security department of the hospital told Mrs. Mu that the doctor had the right to decide if she would add a quota for someone. “But I think she didn’t treat my daughter equally,” said Mrs. Mu, “since she chose to add a quota for the other patient while my daughter was waiting there.”
Liu is another person who complained about her experience of seeking medical advice during the outbreak of COVID-19.
She has suffered from slightly breathing difficulties for a long time. In February, after the outbreak of COVID-19 took a turn for the better, she went to a tertiary hospital in Dalian and booked a doctor of respiratory medicine department.
After waiting for about 1 hour, she entered the inquiry room and saw the doctor. She described her symptoms to the doctor detailedly, but only received a query from the doctor.
“You are really young. I don’t think you may have some illnesses.” said the doctor. But she did not elaborate on the reason for her symptoms. “Maybe you just lack practice.” The doctor thought for a while and made a conjecture without any substantive suggestions.
Under Liu’s repeated requests, the doctor agreed Liu do chest radiography. Another two hours of waiting passes, when Liu brought the chest radiography and reported back to the doctor, the doctor did not even check the X-ray film.
“She just read the report sketchily and concluded that there’s nothing wrong with my respiratory system.” said Liu, “I was a little annoyed not because I didn’t get any effective diagnosis, but it is because she didn’t treat me with any graveness. She concluded that it was my anxiety that made me uncomfortable without checking my chest radiography.”
Liu still suffers from chest distress and shortness of breath until now.
Cases mentioned above are what sometimes could happen during and after the treatment. Two different systems of thoughts exist in doctors’ and patients’ minds, which cause contradictions between them.
Medical dispute cases emerge after incidents happen and patients usually have two solutions, legal approach, and compounding.
The number of medical disputes cases recorded in Chinacourt rose from 24 in 2009 to 3511 in 2019, which is 146 times larger than that in 10 years ago. Although in recent 4 years, the number does not see a noticeable increase, the difference in the level of magnitude still shows a dangerous signal.
“That may be related to the ever-increasing legal awareness of people, but the conflicts between doctors and patients is the main reason.”
Compounding is the other way for patients and their families to ask for compensation from hospitals. Li Bo, a sociologist studying mediation systems for medical disputes, states that patients who are in poor conditions are more likely to adopt compounding as their solutions since legal proceedings always require high costs of time and money.
The rising number of conflict incidents between doctors and patients indicates a noticeable issue that the doctor-patient relationship in China is stuck in a dilemma.
The doctor-patient relationship plays a vital role in health care practices and is a crucial part of the foundations of contemporary medical ethics.
The ever-existing cases of medical disputes between doctors and patients, no matter the violence against doctors or patients’ sue toward hospitals, reflect a cruel but realistic problem, the relationship between medical staff and patients is long-lasting and even has the trend of deteriorating.
According to Baidu Searching Index, the discussion of the relationship
between doctors and patients has maintained continuous popularity among
Chinese netizens during 2011-2019. The research popularity peaks each time
about half a year, which is trusted to be related to hot spots of society,
and then the popularity goes down as the discussion frequency falls, until
the next incidents about the doctor-patient relationship happen.
However, according to the Baidu Media Index, how often the word doctor-patient relationship is mentioned in media reports collected by Baidu, it receives an average of 2 times per day of mentions. In the past three years, the media reports even rarely focus on this issue and the index keeps near to zero.
“Conflicts between medical workers and patients seem quite more thorough
than other relationships,” said a randomly chosen student, Wang, who studies
social science, “I think it is because patients’ life safety is involved
directly in this relationship. You know, it’s human nature to seize for
staying alive and healthy. Thus, there are more tensions in the relationships
between doctors and patients.”
People have different opinions on the reasons for poor doctor-patient relationships. So what are the mechanisms after the tensions?
Looking at the most recent statistics of
the world bank in 2017, the current health expenditure of different countries shows that
the rank of Chinese government’s financial investment of health issues
falls behind the average of the world.
According to the statistics of the World Bank, as shown by the data map of health worker’s possession per one thousand people in different countries, the deeper the color, the richer the medical resources, China does not achieve a satisfying standard overall.
In China, per 1000 people have 1.8 physicians on average, which is slightly higher than the world’s average (1.5) and the average of East Asia (1.6) but lower than most developed countries in Europe, North America, and Australia.
As for nurses and midwives, the average holding quantity is 2.3 for Chinese people, while the average of the world is 3.4, which is 1.5 times larger than that of China.
A doctor who works in a 3A hospital describes one day of her work as follows. She always arrives at the hospital she works in at 7:30 am or even earlier although the ruled time is 8 am. Even though she should have rested on weekends and holidays except for being on duty, she still needs to arrive at the hospital on time, not to mention when she will come off duty. “There have always been patients and their relatives who will get angry if they cannot find me after my working hours.”
That is the situation faced by most health workers, especially those who work in big hospitals.
Another problem is the excessive centralization of patients in metropolis and grade A class 3 hospital. According to the statistics of Chinese authority, 49.8% of clinics are treated in hospitals of the highest class.
These hospitals possess richer medical resources and more experienced medical experts, compared to those small hospitals. As a result, patients are willing to turn to these hospitals for better treatment, which leads to a consequence of medical resource shortage in advanced hospitals while the small hospitals have few patients at the same time.
As shown by the statistics of Chinacourt, Beijing has received the second large number of medical dispute cases, which follows right after Henan (the province that has the largest population). Guangzhou, another province with rich medical resources, reaches 1136 cases, either.
The centralization of patients causes an over-occupation in the advanced hospitals, hence medical disputes emerge. The relationship between medical workers and patients comes up in society.
Since 1949, China has been executing different forms of health care systems, which varied from universal health care under communism to the market-oriented systems since 1984.
A distinguishing feature of the healthcare system that formed in this period was drug price addition policy. Since 90% of medical resources were owned by public hospitals, they have the right of manipulating the whole market to some extent.
Millions of people were left in the reform without insurance coverage, while the delivery of medical services earns the maximum profit. Dr. David Bluementhal, the president of The Commonwealth Fund who conducts research on health care issues around the world, states that this creates a damaging cycle in which patients become vulnerable and suspicious about doctors’ motives. The crisis of confidence between doctors and patients emerges then.
As regulated by the government, hospitals should provide patients with the cost prices of the treatment. However, most hospitals cannot maintain their operation under this policy. Hence, they are allowed to rise by 15% to 20% of the market price of the drugs and sell them to patients. Under this circumstance, many hospitals gain profit by selling additional and unnecessary drugs to patients.
In 2007, medical scholars, Zhang Guizhi, Dong Zhaoju & Wang Jingyan, pointed out in their research paper that the root of conflicts between doctors and patients was the inappropriate health care system.
Ever since 2009, the government implemented a new round of medical system reform, which aimed to make it possible for the public to receive affordable health care services by 2020. Policies are designed to reduce the cost of medical treatment for patients through the new medical system reform.
However, the implementation seems not to be effective in improving the doctor-patient relationship, which is shown in the trend of the Baidu Index.
From 2011 to 2015, the number of research papers on CNKI showed an increasing
trend, which indicates scholars studying doctor-patient relationships became
more and more interested in the issue.
When being asked about her impression of medical workers, the first word that comes up in Wang Yuqing’s mind is service.
“I think the medical industry is a part of the service industry. Private hospitals provide patients with personal services, while the public hospitals provide public services.” The opinion is recognized by quite a few people.
After the outbreak of COVID-19 in 2020, health workers are frequently mentioned in reports of media institutions due to the significant role they are playing in the battle with the virus.
As regulated by the publicity department of the Communist Party of China, the propaganda in China media should be positive and promote the power of ‘positive energy’. Besides, since medical workers have made a considerable contribution to society, their images in media promotion are generally nice or even grand.
Baidu Index shows a noticeable relationship between the word ‘doctor’ and ‘angels in white（白衣天使）’, as shown by the Media Index (the frequency of mentioning in news reports) of the combination of the words.
The two curves tend to move toward the same direction, which indicates that when journalists write reports related to doctors, they will connect them with the phrase ‘angels in white’.
“There are a lot of news reports praising that medical workers always work overtime or certain doctors have excellent medical skills and make a miraculous cure or even bring the dying back to life.” said doctor Li, “I don’t deny that doctors like that do exist in the industry. But in most cases, doctors are just human beings. Actually, I am really helpless about my overtime working. In other words, I don’t want to be like that if I have the choice.”
A netizen expresses his or her opinion on Zhihu under the question: should hospitals set security checks for medical workers’ safety? “The media now loves to promote doctors, teachers, soldiers, police, firefighters, etc. Their selfless spirit makes them heroes and angels in people’s minds. The problem is that if you are a hero once, others may appreciate you and show their gratitude. But when you are always a hero, others will take this for granted.”
Over-positive propaganda increases patients’ expectations of health workers. When facing medical workers in realistic circumstances, gaps between imagination and reality exist, which may disappoint patients. Then, the contradictions between medical workers and patients emerge.
“Either doctors or nurses are just a kind of occupation. We have career moralities and we should be responsible for each patient. But we should not be treated with over-high demands.”
Chinese sociology expert, Wang Xinjian, observes a phenomenon in daily life. Ordinary people in social scenes can easily get angry when seeking medical help, just like drivers can be easily irritated when driving a car. Irritable patients become the potential dangers of violent accidents.
Wang Xinjian analyzes the reasons for the crisis of confidence between patients and medical workers from the angle of attribution of responsibility.
Wang says that China has experienced a long period of social transformation after the reform and opening-up policy. Under this circumstance, traditional social values are shocked, which weakens the power of the existing social regulations and the value system. Hence, the social crisis of confidence comes after the reform. The relationship between doctors and patients is just a part of what has been influenced.
Some scholars (Wang Ru, Wang Zhaoliang) point out that the root of violence against doctors is the unavoidable social contradiction during the period of social transformation.
In addition, the specialty of the healthcare industry intensifies the tension, since some outcomes of medical treatment are unpredictable and irredeemable. As a result, during the process of treatment, each step should be taken carefully, or the vulnerable confidence relationship will be damaged.
Public ownership of social resources is a remarkable symbol of the era that Mao Zedong is in power. The salary of doctors is paid by the state on a monthly basis, and the benefits are paid by the state finance.
The salary is slightly higher than the staff of the government (now civil servants), and the salary of the chief physician is equivalent to the level of the national cadres at the deputy department level. Doctors are only responsible for medical treatment and patients. The financial staff is responsible for collecting medical expenses. Hospital finance implements two lines of revenue and expenditure.
Furthermore, Zhang Ding describes doctors in Mao’s era as kind people. “Doctors serve patients wholeheartedly, and patients trust and respect doctors. They are like family and friends.”
The deterioration of the doctor-patient relationship means both sides’
benefits could be damaged at the same time.
According to a research paper posted on the Lancet, 10-year trends in the production and attrition of Chinese medical graduates: an analysis of nationwide data, the researchers claim that there are 43147915 clinical medical graduates in China from 2005 to 2014, but the increasing number of clinical physicians registered in practice only receive 752233, which takes up 15.91% of the number of graduates.
A commenter under the report ‘the urban legend of "4 million medical students changing careers" hides much anxiety in this industry’ points out the core idea. “Some doctors recommend relatively more expensive medicines to patients for earning profits, which may add financial burden to patients. Some doctors bear much working amount and pressure, which doesn’t match their limited income. There are fewer and fewer doctors and more and more danger in the career. The country and society should pay huge costs. No one will win in the game.”
The top comment under the report is a piece of recruitment information from a medical company. The salary they afford is higher than the average that doctors who are of the same age earn. The company also points out that as they have received too many curriculum vitae, they do not accept the delivery of personnel who do not meet the academic qualifications.
Confrontation damages harmony between doctors and patients. As an afterward behavior, the mediation system of medical disputes has a significant impact on the doctor-patient relationship.
There are basically two types of solutions in dealing with medical disputes. One is civil actions, which is preferred by patients since it is considered that the judgment can be more equitable and patients are more likely to get compensation.
The other way of dealing with medical disputes is civil mediation. Medical staff tends to choose civil mediation as solutions because it requires less cost of money and time, compared to civil actions. Also, they reckon that there exist instances of favoritism on patients in judicial ways.
Referring to statistics of the World Health Organization, till 2018, there are 3396 organizations of people’s mediation in medical disputes in China and more than 25,000 people are working on these organizations. Among the organizations, 55% of them get financial aid from the government.
Li Bo, a medical jurisprudence scholar, conducts research on the experimenting of medical disputes mediation systems in medical disputes in China. As for the exercise of the mediation systems in China, it varies from region to region. For Tianjin, Ningbo, Hainan city, insurance companies serve as important roles in mediation to guarantee the effectiveness and amount of the compensation.
Less than 10% of medical institutions take part in medical responsibility insurance until 2014. The department of health appeals to advance the project of medical accident compulsory liability insurance. After the happening of medical disputes, patients do not need to get in touch with medical staff directly, but they should turn to insurance companies for applying for compensation.
In Chongyang County, Hunan Province, a fixed portion of medical institutions’ income is set as a security deposit of medical disputes’ mediation, which also aims to compensate patients on time with enough money.
Some other places practice a single mediation system without a guarantee of compensation. During the procedure of mediation, professional organizations become judges.
In Li’s opinion, it is the doctor-patient relationship losing the basis of trust that causes socially unsettling. The significance of the mediation system is to alleviate tensions between doctors and patients.
Not only in China, but other countries also have the same difficulties
in dealing with medical disputes. Some trials of different countries have
achieved preliminary effects and are considered to be useful in China,
In Sweden, the no-fault compensation system is used for reference in the medical disputes’ mediation system. The core idea of the no-fault compensation system is not to blame anyone’s fault involved in cases.
Sweden County Council serves as an insurance applicant and insures the patients to the insurance companies. When medical accidents happen between doctors and patients, insurance companies would pay for compensation for all satisfactory patients without judging responsibilities and fault. The compensation amount will be decided together by the deliberative council and professional medical advisor.
Research about the no-fault compensation system conducted in 2020 indicates that the no-fault compensation system
is helpful for the exposure of all the details in accidents and the reduction
of conflicts between medical staff and patients, which can improve the
Germany applies authentication and mediation systems together in the application of mediation of medical disputes, which consists of two organizations, the authentication council, and the mediation council.
The core idea of the system is the fairness of the judgment. According to statistics, 52% of doctors think that their benefits are sacrificed during the mediation system.
When dealing with realistic disputes, a team formed by lawyers and doctors will give advice to people involved in the accident about the form and amount of compensation after discussing and researching the case’s details.
The mediation system in Germany has three principles. Firstly, parties in action have the right to choose whether to accept mediation or not. Secondly, they only give advice without constraint in law. Thirdly, the mediation expense should be free so that it can encourage more people to choose this approach.
The Alternative Dispute Resolution (ADR) has been valued highly in recent years in Taiwan. As the number of medical disputes authentication cases grows to 547 in 2011, which is 3.77 times larger than 145 in 1987, the ADR has received more attention than before and it is valued for its effectiveness.
The idea of ADR is to use different approaches like conciliation, mediation, and arbitration to replace litigation, which can reduce the cost of time and money for both medical staff and patients in a way that is less aggressive.
Rita Charon, a clinical medicine professor at the University of Columbia, put forward the term “narrative medicine” in 2001, which emphasizes the importance of doctors’ understanding of patients’ pain and lifts biological medicine to a spiritual level.
She holds the opinion that complicated contemporary medicine is distant and indifferent. The improvement of the medical technique sacrifices the relationship between doctors and patients. Doctors seem not to have enough time and empathy to understand the sufferings of patients, which is required for patients indeed.
The mediation system serves as a remedial measurement after the fact. An appropriate mediation system can not only deal with the doctor-patient dispute cases but also it can recover the relationship between patients and medical workers.
In cases of medical disputes, the patients vigorously denounced the doctors in the name of justice and axiom, which ultimately only exchanged them at an unreasonable low price. Doctors disguise errors with excuses, counterattack with defensive medical treatment, and puts pressure on legislators to limit patients’ civil litigation rights, which caused both doctors and patients to be hostile to each other.
The ideal state of the relationship between medical workers and patients has still not been found by people. The direction of every effort people make is to explore different approaches to pursuing a better mode for the relationship.
One point that needs to be clarified is that doctors want to cure each patient, and patients want to get appropriate and effective from physicians. No one means to hurt each other during the process. With this consensus, every step Chinese people take would receive a better effect.