BY SOPHIA YIN
For Chinese doctors, patient satisfaction can be—quite literally—a matter of life or death. Official data from China’s Ministry of Health reported “9,831 ‘grave incidents’ of medical disputes in 2006, with 5,519 medical staff injured and 200 million yuan (over 29 million dollars) in property damage.1 Such violent incidents are widespread across the country. In September of 2011, a Beijing calligrapher became so dissatisfied with his throat-cancer treatment that he stabbed his doctor seventeen times.2 In Wenling City in 2013, a patient attacked three doctors, killing one of them.3 In February 2014, patients “paralyzed a nurse in Nanjing, cut the throat of a doctor in Hebei, and beat a Heilongjiang doctor to death with a lead pipe.”4 Just last year in Guangdong Province, a knife-wielding patient chased a doctor down the halls of the hospital, slashing her arms and legs.5 Such reports of dissatisfied patients attacking their doctors are becoming increasingly common in China. The Chinese Hospital Management Association found that “violence against medical personnel rose an average of twenty-three per cent each year between 2002 and 2012. By then, Chinese hospitals were reporting an average of twenty-seven attacks a year, per hospital.”6 Violence toward doctors is not rare or limited to China––such acts are often symptomatic of a larger societal frustration toward the healthcare system. But why are assaults on doctors so prevalent in China specifically?
To answer this question, many legal experts point to the lack of a unified medical negligence legal system. The United States, in contrast to China, has an established and commonly used system of laws dealing with medical malpractice.7 A patient in America must show that the physician “acted negligently in rendering care, and that such negligence resulted in injury” by proving “(1) a professional duty owed to the patient; (2) breach of such duty; (3) injury caused by the breach; and (4) resulting damages.”8 Damages are usually awarded in the form of money and typically take into account actual economic loss as well as pain and suffering.9 Though the US medical malpractice system is by no means perfect, it generally provides an adequate avenue for expressing grievances. Injured patients are less likely to feel the need to take matters into their own hands outside of the law.
In China, on the other hand, medical negligence laws are less uniform. Since the State Council announced the Regulations on Handling Medical Accidents in 1987, medical negligence laws been separately written and enforced by both the government and health administrative agencies, which often leading contradictions.10 The system tended to favor medical care providers by constraining “the scope of medical negligence liability to the narrowly defined medical accident (so that many adverse events are not actionable)” and limiting the damages considered recoverable.11 In 2002, a major reform created the Supreme People’s Court, China’s highest level court, “establishing a distinct judicial medical liability regime”, but it was not until the passing of the 2010 Tort Liability Law that the two regimes were bridged.12 The Supreme People’s Court has also recently introduced many pro-plaintiff judicial rules “to reduce the plaintiff’s costs of proving negligence (by shifting the burden of proof to the defendant), to extend the scope of liability (to cover non-medical accident negligence), and to increase the damages recoverable.”13 As a result, the Supreme People’s Court reported that “courts nationwide heard nearly 17,000 medical malpractice claims in 2010, an increase of 7.6% over 2009.”14 Despite decades of legal reforms and strengthening of legal institutions, there has yet to be a large-scale reform of China’s medical-malpractice legal system.
Some actually criticize the development of the legal system as a part of the problem. A report by Yu et al. written in 2015 cited “increased awareness of patient’s rights, and legal consciousness as well as poor quality of medical services” as “the most important reasons for the increasing acts of violence against the healthcare professionals.”15 The study explains that as patients became more aware of their rights, “patients and their relatives no longer remain silent regarding medical malpractice or medical negligence on the part of doctors or nurses.”16
Perhaps social factors are more at the root of patient anger than legal systems. In China, there is very little trust in the doctor-patient relationship. One reason for this is rising healthcare costs. In the 1980s, the government “reduced subsidies for hospitals and at the same time allowed them autonomy to earn income from sales of services and drugs.”17 With less money flowing in, hospitals responded by charging more for and possibly overprescribing tests and medications. Over this same period, the proportion of the population with insurance coverage also decreased, falling from 70% in 1981 to 20% in 1993.18 As of 2008, “households’… out-of-pocket payments… are more than 18 times what they were in 1990.”19 More than 35% of urban households and 43% of rural households said they had difficulty in affording health care” in 2006.20
To address these problems, the government recently began healthcare reforms to give social health insurance to more of the population, allowing “more than 95% of the 1.3 billion Chinese people [to have] a basic safety net.”21 However, this insurance coverage is incredibly basic, “leaving patients liable for about half of total healthcare spending, with the proportion rising further for serious or chronic diseases such as cancer and diabetes.”22
With the costs of hospital care being so high, many naturally expect correspondingly high quality care. These expectations are rarely met. Doctor-patient interactions are often extremely brief, limiting the ability to form a strong doctor-patient relationship. I observed this first-hand in China two years ago, when I shadowed some Chinese doctors as a part of the Yale MedX trip. Walking into Xiangya First Hospital (located in Changsha, capital of Hunan Province) felt more like going into a shopping mall on Black Friday than entering a hospital. The escalators were packed. The lines for registration numbers or to pick up medicine stretched for miles. The waiting rooms looked like New York City train terminals. The lobby overflowed with people. Dr. Li, whom I was shadowing, explained that people were seen on a first-come, first-serve basis. Many of the people who we saw had arrived around 6 a.m. to stand in line for a registration number.
Some of the hospital crowding can be explained by China’s high population density. Xiangya First Hospital was especially affected because it was a major hospital in a major city. People from surrounding rural areas congregate at such major hospitals in order to receive better care, even though transportation is often expensive. Doctors are rushed through each patient interaction in an effort to see as many of the sick as possible. Even with minimal doctor-patient interaction, many have to wait multiple hours before seeing a physician.
While in China, I also visited the office of a neurologist as he met with patients. By the time I made my mid-morning visit, he had already treated 40 patients. In the fifteen minutes that I was with him, he saw four more. Doctors in China must be extremely efficient, and therefore impersonal – they have no time to converse casually and form a relationship. The physician glances at scans, asks about symptoms, makes a diagnosis, prescribes treatment, and sends the patient on her way. Even before a patient’s meager time with the doctor is technically finished, the next patient in line often interrupts their appointment, knocking on the door loudly or even pushing into the room, trying to hurry the doctor.
What we observed seems to be typical of what Chinese doctors face every day. As Dr. Zhong Nanshan, one of China’s most respected doctors, stated at a 2014 meeting of the National People’s Congress in Beijing, “The reality for patients is wait for three hours to see a doctor for three minutes.”23 Christopher Beam, a journalist for The New Yorker, interviewed a leading radiologist in Shanghai, who recounted that “the record number of patients seen in a day is three hundred and fourteen, which equates to ‘One doctor, 8 a.m. to 6 p.m., ten hours, two minutes per patient’.”24 A study done in the Shaanxi Province of China found that “the average visit to a doctor’s office lasts seven minutes, and physicians spend only one and a half minutes of that time talking to the patient.”25 In the United States and Sweden, the average visit is usually at least twice that.26 In seven minutes there is barely enough time to establish a diagnosis, much less a relationship.
There are clear bases to patient frustration in China. And while systematic medical inefficiency does not excuse a patient’s violence, one can empathize with these victims of a harsh system. Christopher Beam recently wrote about the series of events that led Li Mengnan, a seventeen-year-old patient, to fatally stab Dr. Wang Hao and slash three others. When the news first broke of the killing, the media reviled Li. But as new details emerged about him, “the media’s portrait of the killer softened: Li Mengnan wasn’t a lunatic, nor did he have a history of violence. He was a man whom society had failed so completely that he was impelled to lash out.”27
Beam reported that, after a rough childhood, Li was working in Beijing at the age of fifteen when he began to have severe leg pain.28 He went to the hospital, but was unable to afford the tests necessary for a full diagnosis.29 He returned home to rural Mongolia, where he was unable to receive treatment since the local hospital, like most rural ones, did not have the specialists and equipment needed to make complex diagnoses.30 In September of 2010, Li and his grandfather took a ten-hour train ride to Harbin, the nearest major city, to visit a top-tier hospital.31 Like all major hospitals, the hospital was incredibly busy, and his doctor, very sadly, misdiagnosed him.32 Because Li was not getting better with the treatment the doctor prescribed, he and his grandfather returned to the hospital in April, where he received the correct diagnosis of ankylosing spondylitis, a “chronic inflammatory disease that can result in a complete fusion of the vertebrae.”33 The disease cannot be cured, but doctors proposed treating the symptoms with Remicade, an intravenous drug that costs “thirty-nine thousand yuan (more than six thousand dollars) for the course of injections.”34 Though Li had some insurance as a migrant worker, he still needed to pay eighty thousand yuan out-of-pocket, which the family “scraped together…using Li’s welfare subsidies and his grandfather’s pension, and borrowing the rest from family and friends.”35 The Remicade injections relieved Li’s symptoms, but after a month, doctors told Li they would have to halt the injections because he had tuberculosis, likely because the drug had weakened his immune system.36 Li spent the next four months in a hospital in Hulunbuir being treated for his tuberculosis.37 Then, once again, Li and his grandfather made the ten-hour trek to Harbin, optimistic that Li could restart his Remicade injections.38
When the arrived at the hospital, “the doctors at the hospital had sent him across town to a clinic for an X-ray, only to tell him, when he came back, that he should have brought the clinic’s notes with him. When he returned with this paperwork, they told him that they couldn’t treat his spinal problem after all” because the tuberculosis had not completely left his system.39 Li was told that he would have to wait three more months for the Remicade treatment and would thus have to return home untreated.40 Even worse, “the doctor didn’t tell Li the bad news directly; instead, he made him stand outside his office while he talked to Li’s grandfather.”41 This moment, according to Li’s lawyer, was when “his client felt most insulted and led him to think, ‘Are the doctors tricking me?’.”42 As Li’s lawyer stated, “ ‘All he knows is he’s been there many times, and each time it’s ‘No, no, no.’ ”43 Li had to suffer through high costs, long travel and wait times, and years of waiting – first, for the right diagnosis and then, for the tuberculosis to be treated.
With little trust in the system or his doctors, Li’s anger turned deadly. He left the hospital and bought a three-inch fruit knife from a nearby store.44 Though “he later said that he’d been looking for the doctor who had refused to treat him…when he came out of the elevator he approached the first white coat he saw,” stabbing Dr. Wang Hao.45
At the trial, Li’s lawyer argued that, “the hospital had detected tuberculosis before giving Li the injections, inviting the suggestion that it hadn’t said anything because the medication is so lucrative.”46 Essentially, the lawyer argued that because the hospital exploited a sick patient for his money, disregarding his well-being and treating him as a cash funnel, Li’s sentence should be mitigated. But the judge was not to be swayed: Li is now serving a lifetime in prison.
On the second anniversary of Wang’s death, Beam interviewed the parents of the murdered doctor. He asked Wang Dongqing [Wang Hao’s father] whom he blamed for his son’s death.47 Though very much still grieving his son’s death, Wang Dongqing replied, “I blame the health-care system…Li Mengnan was just a representative of this conflict. Incidents like this have happened many times. How could we just blame Li?”48
How can China fix such a broken system? Its issues are complex and tangled, without a simple or complete solution. Some experts have proposed a return to community care, a practice which has a lengthy history in China. In the twentieth century, China had great success with “barefoot doctors.” Though these were not highly technically trained doctors, they were able to provide basic health services, such as primary and preventive care as well as maternal and child health.49 Barefoot doctors focused on serving rural and underserved areas at the village level, allowing them to vastly improve the health of those they served as well as to forge personal relationships with their patients.50 As a result of the barefoot doctors, the infant mortality rate in the country from 200 per 1,000 births to 34 deaths per 1,000 births between 1952 and 1982.51 The ability for these healthcare providers to form close relationships with those they served allowed for greater trust.
The incidents of attacks against doctors are often a manifestation of the broad frustrations for the inadequacies of the healthcare system. High healthcare costs, poor relationships between doctors and patients, and the lack of well-established malpractice laws are all problems to tackle. Solutions that focus on establishing a wider network of reliable primary health care providers who can form close relationships with those they serve show great promise. Not only will health outcomes of those in rural areas likely improve, but much of the pressure on doctors in urban hospitals will be relieved. With fewer rural patients coming in for minor illnesses or waiting for minor illnesses to become major ones that necessitate going to a major hospital, urban doctors will hopefully have more time to form relationships with their patients, reducing the likelihood that a dissatisfied one returns for revenge.
Sophia Yin is a junior in Berkeley College majoring in Psychology, Neuroscience Track. Contact her at sophia.yin@yale.edu.
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References:
[1] Zeng, L. (2007). 中国去年发生近万起扰乱医疗秩序事件伤五千人. China News. Retrieved from http://news.hsw.cn/system/2007/04/18/005230555.shtml.
[2] Jiang, J. (2011). In Some Chinese Hospitals, Violence is Out of Control and It’s Doctors Who Are at Risk. TIME. Retrieved from http://content.time.com/time/world/article/0,8599,2096630,00.html.
[3] Rauhala, E. (2013). Kung Fu Doctors: Shanghai Hospitals Train Medical Staff for Attack. TIME. Retreived from http://world.time.com/2013/11/06/kung-fu-doctors-shanghai-hospitals-train-medical-staff-for-attacks/.
[4] Beam, C. (2014). Under the Knife. The New Yorker. Retrieved from http://www.newyorker.com/magazine/2014/08/25/under-the-knife.
[5] Rauhala, E. (2015). Chinese doctors to disgruntled patients: Please stop stabbing us. The Washington Post. Retrieved from https://www.washingtonpost.com/news/worldviews/wp/2015/07/22/chinese-doctors-to-disgruntled-patients-please-stop-stabbing-us/.
[6] Beam, C. (2014). Under the Knife. The New Yorker. Retrieved from http://www.newyorker.com/magazine/2014/08/25/under-the-knife.
[7] Bal, B.S. (2009). An Introduction to Medical Malpractice in the United States. Clinical Orthopedics and Related Research, 467(2), 339-347.
[8] Ibid.
[9] Ibid.
[10] Liebman, B. (2013). Malpractice Mobs: Medical Dispute Resolution in China. Columbia Law Review, 113(1), 181-264.
[11] Ibid.
[12] Ibid.
[13] Ibid.
[14] Ibid.
[15] Yu, H., Hu, Z., Zhang, X., Li, B., & Zhou, S. (2015). How to overcome violence against healthcare professionals, reduce medical disputes, and ensure patient safety. Pakistan Journal of Medical Sciences, 31(1), 4-8.
[16] Ibid.
[17] Ramesh, M., Wu, X., & He, A.J. (2012). Health governance and healthcare reforms in China. Health Policy and Planning, 29(6), 663-672.
[18] Ibid.
[19] Hu, S., Tang, S., Liu, Y., Zhao, Y., Escobar, M., & de Ferranti, D. (2008). Reform of how health care is paid in China: challenges and opportunities. Lancet, 372(9652), 1846-53.
[20] Ibid.
[21] Yip, W. & Hsiao, W. (2015). What Drove the Cycles of Chinese Health System Reforms? Health Systems & Reform, 1(1), 52-61.
[22] Reuters. (2016). China Healthcare Costs Forcing Patients into Crippling Debt. Fortune. Retrieved from http://fortune.com/2016/07/10/china-healthcare-costs-debt/.
[23] Woodhead, M. (2014). Dr. Zhong Nanshan: What’s Wrong with China’s Health System and Why We Need to get Doctors on Board to Fix It. Chinese Medical News. Retrieved from http://www.chinesemedicalnews.com/2014/03/dr-zhong-nanshan-whats-wrong-with.html.
[24] Beam, C. (2014). Under the Knife. The New Yorker. Retrieved from http://www.newyorker.com/magazine/2014/08/25/under-the-knife.
[25] Ibid.
[26] Dugdale, D.C., Epstein, R., Pantilat, S. Z. (1999). Time and the Patient-Physician Relationship. Journal of General Internal Medicine, 14(Suppl 1), S34-S40.
[27] Beam, C. (2014). Under the Knife. The New Yorker. Retrieved from http://www.newyorker.com/magazine/2014/08/25/under-the-knife.
[28] Ibid.
[29] Ibid.
[30] Ibid.
[31] Ibid.
[32] Ibid.
[33] Ibid.
[34] Ibid.
[35] Ibid.
[36] Ibid.
[37] Ibid.
[38] Ibid.
[39] Ibid.
[40] Ibid.
[41] Ibid.
[42] Ibid.
[43] Ibid.
[44] Ibid.
[45] Ibid.
[46] Ibid.
[47] Ibid.
[48] Ibid.
[49] Brink, S. (2015). What China Can Teach the World About Successful Health Care. NPR. Retrieved from http://www.npr.org/sections/goatsandsoda/2015/04/03/397158218/what-china-can-teach-the-world-about-successful-health-care.
[50] Ibid.
[51] Ibid.
Yale Global Health Review 