Why is there so much violence against doctors in China?

by MICHAEL WOODHEAD
As I've said many times on this site, the level of violence against medical staff in China is extraordinary. In one province, Guangdong, there were 25,000 recorded incidents last year alone. Many reasons have been put forward by academics and politicians to explain the epidemic of violence - but there has been little actual study of the contributing factors. Now researchers have interviewed patients and medical staff in seven Guangdong hospitals to get some feedback from the grassroots.

The results of the survey are published in the BMJ this month and one theme emerges: mistrust.

The survey found that there was widespread mistrust of doctors and healthcare staff by the public, based on well-grounded beliefs that there was widespread injustice and commercial bias in the Chinese healthcare system. Patients believed that decisions on their treatment were based more on hospital revenue than need, while at the same feeling resentment that they had to wait for hours to see a doctor for just a few minutes. Costs and financial injustice were a major source of anger: people cited examples of patients being refused treatment - or having treatment terminated due to inability to pay fees.

Doctors also believed there were major injustices in the healthcare system - saying their workloads were far too high and the salaries did not reflect their years of training, long hours and high pressure. They also said that they did not trust patients to behave in a civilised manner, with many being demanding or suspicious.

Patients had little trust in the official dispute resolution systems. They believed that hospitals and law courts were unlikely to give time or serious attention to patient complaints and felt there was little chance of redress for any deficiencies or mistakes. For this reason, patients said they would be more likely to get a result - an apology and compensation - if they used physical and verbal threats, disruption of the hospital and violence to gain attention.

The survey also heard from doctors that their training had not prepared the for communicating with patients or having a good bedside manner.

Both patients and physicians were critical of the government's response to rising violence - namely increasing levels of security guards at hospitals. They said this just inflamed the situation, creating a siege them-and-us mentality and did little to address sudden violent assaults on staff.

The researchers - including several China-based doctors - are openly scathing about the policy response from Xi Jnping and his administration.

"The moral crisis that our study revealed in Chinese healthcare demands a legal and regulatory response as well as a moral one. The Chinese phrase “zhibiao bu zhiben” means treating the symptoms and not the disease. Cracking down on violence and enhancing security measures are unlikely to fundamentally alter patient–physician mistrust and may inadvertently undermine trust."

They put forward three policy suggestions to tackle the climate of mistrust that is driving the violence in healthcare. Firstly they say hospital 'commissions' and incentives to staff for overservicing must be abolished and financial conflicts of interest must be addressed.

Second, doctors and hospital staff need better training in communication, ethics, professionalism and dispute resolution. Finally, there needs to be an atmosphere of trust in which the public are willing to negotiate and seek non-violent solutions, while doctors must be willing to apologise to patient families and accept reasonable consequences for medical error. st.

Similar findings were made in a separate study of junior doctors in three Nanjing hospitals recently. The study found that junior doctors felt extremely frustrated at having studied for up to a decade but having only a lowly job title and poor pay. The doctors said they worked extremely long hours and had high pressure in their work, but also faced poor prospect for promotion or increasing their income. The other main finding was that most junior doctors had experience of abuse and violence from the public, and this was a major contributor to poor quality of life.

"Although Chinese doctors feel relatively unsafe, the phenomenon does not raise sufficient concern from hospital managers . These violent events negatively affect medical workers; for instance, these workers may develop guilt and self-doubt, and such outcomes can reduce the quality of services," the study authors note.

Nanjing Hospital nurse and doctor injured in attack by top official

by MichaelWoodheadA dispute over male and female patients being forced to share the same ward is supposedly the cause of an attack by a senior Nanjing official on medical staff that left a nurse paralysed.
A nurse has been severely injured in what has been described as a vicious attack by a senior female official who is head of the Jiangsu Science and Technology Institute. The incident occurred on 24 Feb at the Nanjing Stoma Hospital when a young man was brought in for emergency surgery for a bleeding cyst. Because the hospital was full and had few vacant beds, the young man was allocated to a female ward to recover from the operation, and was to be moved to a male ward when a bed became available. However, when he woke from the anaesthetic and realised where he was he called his family and they hurried to the hospital to demand that he be moved to a male ward. When a nurse said this was not possible she was beaten by the mother of the young man. The nurse was beaten with the handle of an umbrella and the attack was so violent that the handle snapped. The nurse received severe injuries to her chicest and was left paralysed in her legs and unable to move. A doctor on duty was also assaulted and severely bruised.
The official is now under investigation by local police. However, the incident has been widely reported on social media sites such as Weibo, with many saying that it is typical behaviour from arrogant and privilege officials. The young man's father is an official in the Nanjing procurator's office and many doubt the injured nurse will see justice for those who attacked her.

Chinese people with diabetes have poor insulin injection techniques

by Michael Woodhead
People with type 2 diabetes have poor insulin injection techniques that cause bruising, bleeding and lumps in the skin, a Nanjing study has found.
A survey of the injection techniques of 380 patients with diabetes from 20 centres across China found that their injection techniques with insulin pens were poor and they often re-used single use needles.
The survey found that 36% of patients had lipohypertrophy (fatty lumps under the skin) and 57% of patients had bleeding and bruising, and abdominal lipohypertrophy at injection sites. The re-use of single use needles was a major factor in lipohypertrophy, and there was also a link with rolling the insulin pen while pulling out the needle after injection.

"The bleeding and bruising at the injection sites may be associated with suboptimal absorption of injected insulin. Improved education in optimal insulin injection technique, including reducing needle reuse and correct rotation of injection sites should be emphasized, the researchers concluded..

The study was conducted by Lou Qingqing  and Ji Jiajia at the Jiangsu Province Hospital, Nanjing. The findings are published in Current Medical Research and Opinion.

Nanjing man with kidney failure survives for 13 years with home-made dialysis machine

Hu Songwen: "The principles of hemodialysis aren't complicated."

by Cang Wei and Song Wenwei 
An impoverished uremia patient has moved the public by constructing his own hemodialysis machine to stay alive.
Doctors agree it's a miracle that Hu Songwen has survived for 13 years because of his homemade hemodialysis machine.
The man recalls his life fell apart when he was diagnosed with uremia in 1993. He was a 21-year-old Nanjing Institute of Meteorology senior.
That morning, his face swelled. He had difficulty urinating. And he couldn't even stand on his own.
A medical examination showed both of his kidneys had failed.
The institute paid Hu's expensive medical bills for a year. It then sent him home to Qutang township in Jiangsu province's Hai'an county.
Hu's parents were factory workers, but each hemodialysis session cost 400 yuan ($64). At that time, his parents earned less than 1,500 yuan a month, but Hu needed more than 4,000 yuan every month to live.
The parents had done everything possible to save their son. In less than a year, they sold all their valuables and borrowed money from all of their relatives. After the money from the government and Hu's friends were spent, they couldn't afford food or housing.
"Do nothing but wait for death?" Hu says.
"I couldn't."
After reading books about the principles of hemodialysis, Hu - who excelled at chemistry and physics in high school - bought a cheap secondhand blood pump online and asked an acquaintance to purchase hemodialysis tubes.
"The principles of hemodialysis aren't complicated," Hu says.
"I had confidence I could overcome the difficulties I'd face."
On March 31, 1999 - a day he says he'll never forget - his homemade hemodialysis machine, filled with purified water and drugs, started to operate in his home's bathroom, which is smaller than 5 square meters.
Every tube used for hemodialysis costs about 100 yuan. To save money, Hu uses each more than 10 times, while they're only used once in hospitals.
He doesn't share the fears of many people around about bacterial infections and pollution.
"I just need to master the drug dosages and make sure to avoid getting any air in my veins," he says.
He used ceramic bowls to pour purified water into a steel pot, and heats the medicine in the microwave.
His 81-year-old mother, Huang Zhongfang, is his only hemodialysis assistant. She uses an old wooden scale to measure the fluid with her trembling hand and then feeds it into the machine.
Read more: China Daily

Officials use loophole to retain 'unfair' free medical treatment

by Alice Yan

Officials to be reimbursed for losing access to free treatment

Civil servants in the eastern city of Nanjing will lose their privileged access to medical treatment next week, making it the last city in the Yangtze River Delta to implement a reform launched by the central government 14 years ago in an attempt to assuage public concerns about the unfair benefits given to officials.
The "free medical treatment" scheme, introduced in the early 1950s, allowed civil servants to receive assistance at public hospitals for little or no cost.
Unlike the employees of businesses, whose medical insurance contributions are deducted from their salaries each month, officials didn't have to spend anything.
Ordinary urban residents on the mainland have to pay about a third of their medical bills, while farmers living in rural areas have to meet half of their hospital expenses.
The central government said in 1998 that all civil servants should relinquish "free medical treatment" and instead join the basic medical insurance scheme used by the employees of urban businesses, making the same contributions and receiving the same level of benefits.
However, local officials in a quarter of the mainland's 31 provinces, municipalities and autonomous regions, and more than 300,000 officials in central government departments, are still hanging on to their unfair benefits.
Nanjing's 200,000 local officials will forfeit their "free medical treatment" cards next month and join the urban employees' basic medical insurance scheme, Modern Express reported following an announcement by the city government. Two per cent of each official's monthly income will be transferred to their insurance account and the department they work for will contribute another 9 per cent of their monthly income to the account.
On the surface, the medical treatment that Nanjing officials receive will be no different from that given to ordinary employees, as claimed by the authorities. But a remark by a senior official paints a different picture.
Chen Jianning , deputy director of Nanjing's human resources and social security bureau, was quoted as saying that besides the basic medical insurance scheme, officials were also entitled to join an additional medical insurance scheme, meaning that most of the money officials pay for medical treatment will be reimbursed.
Officials in many other cities, including Beijing and Tianjin , receive similar favourable treatment. One official from Beijing's municipal human resources and social security bureau who tried to explain the rationale behind the arrangement said it was designed to ensure that civil servants' medical benefits were not reduced under the reform.
The "free medical treatment" enjoyed by government officials has long been criticised by analysts as an unfair privilege. Some officials have even been rumoured to have used their "free medical treatment" cards to acquire free medicine for relatives.
The average medical expenses of a Beijing resident in 2009 were 4,200 yuan (HK$5,150), but the average expenses of a Beijing official were triple that. The capital implemented the reform of officials' medical insurance at the start of this year.
In Guangzhou, city authorities budgeted 1.4 billion yuan this year for the medical expenses for officials, but only allocated 615 million yuan to subsidise hospital visits by 2.1 million farmers, Yangcheng Evening News reported in June.
Civil service jobs, known as "iron rice bowls" on the mainland, have long been highly sought after because they offer stable, long-term employment, better medical insurance and higher pensions. Officials get pensions at least twice as big as other retired workers in their city, without having to make any contributions to a pension scheme at all.
In some affluent cities, a thousand applicants can compete for one civil service job.
With reform of officials' medical insurance benefits being introduced sluggishly and half-heartedly and pension reform stalled, the "iron rice bowl" is likely to maintain its allure for some time to come.
Source: SCMP

Nanjing offers free health checks to migrant workers

Nanjing city launched on Tuesday a free physical examination program for migrant workers at construction sites in the city and the first batch of 170,000 workers have already started to enjoy free physical examination.
The city released in September a new regulation on enhancing basic medical care and treatments for construction workers, which stipulates that all construction operators in Nanjing whose major disease medical insurances are valid can enjoy a free check-up after they receive the Nanjing Resident Card.
Before that, construction workers in Nanjing already enjoyed the favorable policy of “refund for 50 to 80 percent of medical care bills below 800 yuan” and refund for over 80 percent of hospitalization expenses if their medical insurance covers related treatments.
Statistics show there are some 500,000 migrant workers at construction sites in Nanjing.
Source: Jiangsu China

No link between MSG and asthma, Nanjing study shows

Large study found no link between MSG consumption and asthma

by Michael Woodhead
The first major population study to look at the possible role of MSG and asthma has found no link between the consumption of monosodium glutamate and asthma rates.
Dr Shi Zumin, a researcher from the Department of Nutrition and Foodborne Disease Prevention at Jiangsu Provincial Centre for Disease Control and Prevention, Nanjing, undertook a study of MSG and asthma because emerging evidence shows that diet is related to asthma.
In a study of data from 1486 Chinese men and women who participated in the Jiangsu Nutrition Study, MSG intake and dietary patterns were assessed in 2002. Information on asthma history was collected during followed-up in 2007.
Of the study population, 1.4% reported ever having asthma. MSG intake was not positively associated with asthma. However, there was a significant positive association between ‘traditional’ (high loadings on rice, wheat flour, and vegetable) food pattern and asthma. No link with asthma was seen with a diet rich in meat and alcohol, nor for a 'sweet tooth' diet high in cake, milk, and yoghurt, or a ‘vegetable rich’ diet high in whole grain, fruit, and vegetables.
Dr Shi says a MSG was first reported  to be linked to asthma attacks in 1981 after a person developed asthma after ingesting a meal in a Chinese restaurant. However, small clinical trials on MSG and asthma have yielded inconsistent results, with some suggesting that MSG intake was a trigger factor for asthma, while others showing no  link.
He notes that the prevalence of asthma in the Chinese population is lower than Western populations, and the prevalence of asthma (1.4%) in the study was consistent with that of other studies
"In our [study], even though the mean MSG intake is high compared with many developed countries, we did not observe a significant increased risk of asthma," he concludes.
Source: PLOS One

Nanjing to ditch preferential medical plans for government employees

The city government of Nanjing will replace its preferential medical care system for its employees in 2013 with a uniform medical insurance plan that aims to more fairly cover all the city's residents.
Starting January 1, 2013, all government branches and their affiliated organizations in the city will be required to join the medical insurance plan, which will no longer be paid for by the government.
Some 24 regions in China, including Beijing and Tianjin, have already implemented reforms to their civil service medical care plan after preferential medical care plans for government employees triggered widespread grumbling from the public. 
Source: People's Daily

In China, influenza-like illness is caused by many different viruses

In the Chinese winter flu season, human coronavirus is a common cause of influenza-like illness

by Michael Woodhead
Influenza-like illness is a common cause of diseases and disability in China but little is known about the causative viruses in China.
Therefore Dr Huo Xiang and colleagues at the Jiangsu Provincial Center for Disease Control and Preventionin  Nanjing screened almost 500 patients with influenza-like illness over a one year period  in Nanjing.
In their study, viruses were detected in samples from half the patients with influenza-like illness, and the viruses detected most frequently were influenza A (23%), influenza B  (8%), influenza C 30 (6%) patients, and rhinovirus (6%).  All other viruses such as human coronaviruses and respiratory syncytial virus (RSV) were found in less than 5% of patients.
Interestingly, the predominant types of viruses seen in influenza varied by season. Rates of influenza A and human coronavirus illness were much higher during the  winter peak 'flu season' than during the summer and other months. Co-infections were seen in 12% of patients.
"This study confirmed that multiple respiratory viruses may circulate concurrently in the population and account for a large proportion of influenza-like illness.
And the proportion was much higher in January (67%) than in June–August (33%), which was consistent with other findings indicating that respiratory viruses are more likely to be associated with influenza-like illness peak in winter rather than peak in summer.
The influenza-like illness peak in summer may be due to other respiratory pathogens including bacteria, chlamydia, or mycoplasma, the researchers say.
Also of interest was the observation that RSV was rarely a cause of influenza-like illness in China, as it is the most common cause of lower respiratory tract disease and the leading cause of hospital admission among young children worldwide
 "In the present study on outpatients with influenza-like illness, RSV was common in children up to fifteen but was not detected in other age groups, which may be attributed to the developing immune state and vulnerability to infections," the researchers note.
"In conclusion, this study confirms that multiple respiratory viruses may circulate concurrently among the population and account for a large proportion of influenza-like illness. In addition to influenza A, human coronavirus may be associated with the influenza-like illness winter peak in Nanjing, China, 2011."
Source: Journal of Medical Virology

Eradication regimens have poor efficacy against H. pylori in China

Most of the first and second line eradication drug regimens have poor efficacy against H. pylori infection in Chinese patients, a study from Nanjing has shown.
Researchers from the Department of Gastroenterology at the First Affiliated Hospital of Nanjing Medical University assessed the efficacy of standard sequential therapy for H pylori (five days of treatment with a proton pump inhibitor [PPI] and an antibiotic such as amoxicillin followed by five days of treatment with the PPI and two other antibiotics such as clarithromycin and tinidazole) and the efficacy of levofloxacin-containing triple therapy and levofloxacin-containing sequential therapy.
Their study showed that the H pylori eradication rate was 83% for the standard sequential therapy compared to 81% for levofloxacin-containing triple therapy and 87% for levofloxacin-containing sequential therapy.
The researchers conclude that : "standard sequential therapy and seven-day levofloxacin triple therapy produce unacceptably [low] therapeutic efficacy in China. Only levofloxacin-containing sequential therapy achieved borderline acceptable result. None of the regimens tested reliably achieved 90% or greater therapeutic efficacy in China."
Read more: Helicobacter

Chinese people lack crucial knowledge on health insurance

Nanjing residents have little or no knowledge of medical insurance

by Michael Woodhead
Most people in China know little about health insurance, despite the government planning a move towards an insurance-based healthcare system, a Nanjing surrey suggests.
Researchers surveyed more than 1000 households in Nanjing and found that even those people who were  insured had limited knowledge about their health insurance schemes.
Their findings showed that people who had chosen to be insured were more likely to have accurate knowledge of their plan than those were automatically covered. People who had recently sought medical care had better knowledge of their insurance plans than those who were healthy or did not seek care in the same period. This suggests that the level of consumer information was positively influenced by respondents' motivation to obtain relevant information.
The researchers say that adequate consumer information is a crucial pre-condition before changing to a health insurance-based health system.
"The results from [our study] demonstrate that the current level of consumer information about health insurance is low," they say.
"We conclude that the level of consumer information is currently insufficient in China. If the Chinese government is determined to adopt market mechanisms in the healthcare sector, it should take the lead in making valid and reliable information publicly available and easily accessible."

Read more: International Journal of Health Planning

Nanjing hospital's RMB 7 million piano sparks outrage

The RMB 7 million piano in the lobby of the Nanjing Gulou Hospital

by Michael Woodhead 
Nanjing Gulou Hospital has been criticised for installing a RMB7 million piano in the lobby of its new building.
The Gulou Hospital, a leading public hospital in the city, has been overwhelmed with criticism about the value of the new piano, which it said was installed as part of a lobby coffee shop to create a soothing and comfortable atmosphere for patients and visitors.
Nanjing residents said online that public hospitals should certainly improve their medical environment, "but these environmental improvements should focus on treatment services directly related to the hospital, such as easing the suffering of patients, more spacious and clean treatment rooms, more comfortable seating and more functional beds. "
Critics said  that an expensive piano and a coffee shop are not essential facilities for a public hospital. "If you want to listen to music you can go to the mall or hotel, you can go to Starbucks to drink coffee, the hospital only needs to focus on treatment rooms, beds and clinic facilities for patients."
Read more: China Healthcare