PHYSICIAN, HEAL THYSELF

BY GINGER HUANG (黃原竟)

PHYSICIAN, HEAL THYSELF

BY GINGER HUANG (黃原竟)

Doctors and nurses stand alone against violence and a corrupt system

當(dāng)我們老了，還會有醫(yī)生給我們看病嗎?

“WHEN THEY ATTACK, I AM NO LONGER A DOCTOR; I'M A CITIZEN, AND A CITIZEN HAS A RIGHT TO DEFEND THEMSELVES.”

Thirty-year-old Fang Hua, an ER doctor in a Beijing hospital, would seriously reconsider applying for medical school if she could do it all over again. In 2009, Fang obtained a Ph.D. in cardiology from Peking University Health Science Center, one of the top medical schools in China, and then began working in one of the most reputable hospitals in Beijing. All in all, it looked like a promising career on the rise, but it didn't turn out quite as expected. In the fi rst year, her wages hovered at around 4,000 RMB per month. Having worked for four years, she fi nally got an insignif i cant pay rise, which looked all the more humble considering her workload and conditions. Once a week, she has to take a shift that works her from fi ve in the afternoon to noon the next day, starting right after her normal work day. This means that, once a week, she works a 28 hour shift, seeing over 100 patients. It's not the exhaustion that concerns her: “We are used to the workload, and always got by, but I constantly worry that I may misjudge something and make fatal mistakes. The shortage of staff always causes trouble.”

However, there's an even more threatening force on the ward; for doctors, it can be more deadly than the diseases they face. “On almost every shift, we get a few really cross patients or their families who shout threats at us like ‘I'll kill you' or ‘I'll hack you to death'. Fortunately, none of them have actually carried out their threats on me. I don't know if they would really do it.” The soft-spoken Fang added, “We didn't have this many conf l icts in the past. I don't know why. I only hope we will not become the victims.”

Fang has good reason to fear. Besides the excessive workload and low pay, doctors and medical professionals today face violence from their patients, attacks that have seen a marked increase over the past decade. From 2001 to 2012, over 150 violent incidents against hospital staff have been reported by the media, altercations that vary from physical attacks and kidnapping to public humiliation and murder. According to the Chinese Hospital Management Association, from 2001 to 2012, over 30 doctors died due to patient violence. By 2013, 73 percent of Chinese hospital staff reported being verbally or physically abused by patients. Over 61 percent of hospitals had seenyinao(醫(yī)鬧), patients' demonstrations. In a typicalyinao, the patient's family sets up a mourning hall in the hospital lobby after the patient dies, even bringing in a coff i n, fl oral wreaths, and burning paper money. They accuse the doctors of malpractice or negligence and demand compensation.

This year has already seen more than its fair share of atrocities: 45-year-old doctor Sun Dongtao was beaten to death after an allegedly unsuccessful surgery; 38-year-old Li Aixin had his throat cut by a patient for the same reason; 20-year-old nurse Chen Xingyu was attacked by a patient's parents, causing temporary paralysis, because they objected to her ward arrangements; a doctor in Chaozhou, Guangdong Province was publicly humiliated in the street after a patient died of alcoholic intoxication.

This horrif i c series of events has made it even harder for medical professionals to speak out. Public hospitals are theoretically government-owned, and therefore they are not allowed to talk freely to media, just like civil servants. A Communist Party Committee secretary at a medical school, when asked about the rise in violence against medical professionals, toldTWOC, “After what has happened in the last few months, accepting interviews from the media is basically out of question.”

Wen Jianmin is one of the few doctors who will speak openly about patient violence. Wen is a large, barrel-chested man in his 50s, with a square, bespectacled face that gives him an authoritative air. He is an osteologist with 30 years of experience, the director of the osteology department of Wangjing Hospital of China Academy of Chinese Medical Science, twice a delegate on the CPPCC, and an activist campaigning for doctors' rights.

“I know doctors who are picking up taekwondo and nurses who put pepper spray in their front desk—that's how frightened people are in our profession.” Wen Jianmin spoke loudly and angrily: “Imagine our situation: the fi rst thing that concerns us is not how to cure a patient, but how to make sure we survive the day. When the patients grow violent, we call the police, but they stand by and do nothing until the patients smash our desks or start to hit us. And what does the hospital do? They tell us never to return an insult and never fi ght back whenthe patient attacks us. But I never followed this rule.”

He adds def i antly, “I always tell my students to fi ght back when they are attacked and to make sure their seats face the door so that they can notice if an attacker is coming. When they attack, I am no longer a doctor; I'm a citizen, and a citizen has a right to defend themselves.”

WHILE THE LONG WAITS CAUSE A LOT OF COMPLAINT, DISTRUST IS ANOTHER, MORE SERIOUS, ISSUE

Nurses are in an even worse situation than the doctors. Ma, a pharmacy director in a Tianjin hospital who wished to remain anonymous, said, “In my hospital, humiliation and shouting falls on nurses daily because they do things like miss veins for injections or don't react to patients' needs. But, because of the hospital's rules, the staff can never confront a patient— they can only silently weather them.”The 50-year-old woman added sympathetically, “However, you have to know, every nurse is overworked. In all these years, I've never seen a nurse get off work on time at 5 pm. Most of them stay until 11 pm or later. The next morning, they arrive at the hospital at 7 am, as usual. There are no elderly nurses here because you can only stand the work when you are young.”

In response to violence against medical professionals, one medical website made an “Anti-Violence Guide in Hospitals” based on advice given by over 2,000 doctors nationwide. The guide includes suggestions like, “avoid staying in the off i ce on your own or with your back to the door”, “wear sneakers to work”, “save a prewritten SOS message in your phone”, and “shield yourself with your steel clipboard in case of stabbing”.

Where, then, does such hostility come from? Admittedly, part of the conf l icts arise from the fact that some patients simply lose patience. China's best medicalservices are concentrated in big cities. Private hospitals are expensive and sometimes unreliable; public hospitals, especially well-known ones, are permanently overcrowded and understaffed. A trip to the hospital is, sometimes, like going into battle.

IN ORDER TO SURVIVE THE COMPETITION, MOST PHARMACEUTICAL COMPANIES ARE PERFECTLY FINE WITH A LITTLE FOUL PLAY

In order to look at a leg problem, Kong Weizheng decided to go to Beiyi Sanyuan, a hospital known for its expertise in osteology. He awoke at 4:30 am, taking a taxi to arrive at the registration window at 5:45 am, and, to his dismay, in the misty morning well before the fi rst twilight of dawn, the queue was already 20 meters out of the hospital's lobby. When he fi nally got into the lobby, he realized that the line snaked and folded many times over and that the lobby was more crowded than a temple fair. Seven security guards were deployed to keep people in order, and it was far from enough—there were already fi ghts for several spots. Kong got his registration number in what took over an hour and noticed that three departments were already full for the day. When doctors started to see patients at 8 am, the waiting areas in front of their off i ces were already too crowded to move and Kong had to elbow his way anywhere he wanted to go. “And it's not a particularly bad day,” Kong said. “Because when I got out of the taxi and was stunned at the sight, the taxi driver smiled and said,‘Good, it's not that crowded today.'”All over China, big city hospitals have always been this crowded, and things were even worse a few years ago, with a lack of online and phone registration.But even with these advances, spots in the virtual queue are limited.

On Janurary 25, 2011, the gate of Jinhua People's Hospital, Zhejiang Province, was blocked by a family demanding compensation for their loss

While the long waits cause a lot of complaint, distrust is another, more serious, issue. In the past few years, several events have fueled this paranoia for malpractice. In 2010, a man called Chen Cheng sued a hospital in Guangzhou because he believed the doctor sealed his wife's anus with thread because he didn't pay the doctor enoughhongbao, a sort of bonus or bribe. It later turned out that Chen's wife had serious hemorrhoid bleeding and that the doctor had tried to stop it. There was absolutely no proof of Chen'shongbaoallegation. But it was too late; the headlines had already struck.

In 2011, a story spread widely that Shenzhen Children's Hospital suggested a fi stula operation on a six-day-old baby who was unable to defecate, but the father took the baby to another hospital and cured its ailment with just 0.8 RMB worth of paraff i n wax. It later turned out that the wax couldn't cure the baby, who had a congenital megacolon and needed the surgery after all. Both of these news stories caused a serious sensation, and the consequences were hard to undo. At the Shenzhen Children's Hospital, for example, parents started to refuse operations, fearing they were unnecessary.

Of course, malpracticedoesoccur, and that is enough to breed paranoia in even the most conscientious patient. What's more, the fact that most doctors get commission from many of the medicines they prescribe is an open secret. This is one of the dark corners of the medical world in many countries, and China is no different—a reason many distrust and attack their physicians. In order to survive thecompetition, most pharmaceutical companies are perfectly fi ne with a little foul play. Wang Jing, an ex-Sanjin Pharmaceutical Company employee, explains, “We were called pharmaceutical representatives. My job, to put it simply, was to bribe doctors.” Examined closely, the mission of the pharmaceutical rep is complex: “Our fi nal goal was to make the doctor prescribe our company's medicine to patients. For example, when we developed a new medication which was ready to go to market, we needed to fi rst get the medicine's priced byfagaiwei(National Development and Reform Commission, the government authorities that have the fi nal say on the prices of all marketed goods). If it only cost fi vekuaito produce, we couldn't set our price according to the cost alone, so it would get marked up.”

That, according to Wang Jing, is where the doctors come in: “We usually give one fourth of the medicine's fi nal price as commission to doctors. The market's unwritten rule is that, when a doctor gets less than 10kuaifor each box of medicine, you'll get beaten by the competition. That's why there are very few medications cheaper than 40kuaiin hospitals.” Wang Jing claims, “We start by bribing thefagaiweito make sure we get a price high enough. And then, with our pharmaceutical rep off i ces all over the country, we use connections and money, sometimes an agency, to ensure the medicine gets sold in hospitals nationwide.”

With this, everything is fi ne as long as the doctor likes the medicine and believes it is useful. But, if they don't, then Wang would have to bribe the director of the hospital pharmacy, the president of the hospital, the leaders in health bureau who are in charge of the hospital, and even low level government departments to pressure the hospital into prescribing the medicine. “It's ajianghu,” Wang says, using awuxianovel term for“underworld” to describe the world of pharmaceutical marketing.“Everything is done withguanxiand money.”

When asked how much the commission inf l uences doctors' prescriptions, Wang said, “Many doctors will prescribe too much medicine to treat a patient. For example, if it only takes one kind of medicine to treat a cold, the doctor may prescribe three kinds of similar medicines, or simply medicine that lasts much longer than the patient needs. But, what is worse is that the commissions are eroding the profession's work ethic; it is a bad force that makes them more money-driven.”

Wen Jianmin points out that corruption is endemic in the medical system. “The corruption starts from the high end of the hierarchy. Doctors are at the very bottom of the food chain, supporting the whole of it. Iffagaiweidid not allow such huge prof i ts for medications, the producers wouldn't have the money to do all this bribing, and the whole chain would collapse. However, it involves big money and too many parties. No one is bold enough to stop it. It's the whole system that's gone bad.” He adds, “If you bathe every day in an ink tank, will you come out clean?”

Considering the whole profession is usually underpaid, doctors need the money. While medication is often far too expensive in hospitals, manpower is cheap. To see a doctor the registration fee is fi ve RMB; if one wants specif i cally to see a head doctor, the fee is 14 RMB. Having a surgery is usually expensive, however, only a small portion of the expense is paid to the surgeons who actually carry out the operation. Zhao Jianyi, 31, is the mother of twin girls, and one of her babies was born with esophageal atresia, which requires a series of surgeries. When the fi rst surgery was complete, the total hospitalization expense read 194,889 RMB. However, only 1,498 RMB—less than one percent of the total—is the fee charged for the operation. Most of the expenses went in medications.

Fang Hua says: “When we have a surgery, around 10 people—surgeons, anesthetists and nurses—work on the operation for up to a whole day, and the price for all the manpower is usually a little more than 1,000 RMB.”

“I've been a doctor for over 30 years, and back in the 1980s, things were not like this,” Wen Jianmin claims. “At that time, being a doctor was still a respected job, and we were on very good terms with the patients. Things started to get worse from the late 1990s, when the government tried to privatize hospitals, investing in only eight percent of total hospital costs. That means hospitals, critical social welfare organizations, were left on their own to survive.”

Without dignity and underpaid, young people are less willing to become doctors. Furthermore, doctors who want to keep their jobs are largely keeping quiet about the effects of corruption. With fear abounding and the lure of money, the whole profession is being drained of vitality, ethics, and morale. “If the whole institution doesn't change,” says Wen Jianmin gloomily, “what I worry about most is that, when I become old and need doctor, there won't be a doctor I can turn to.”