Are China's doctors happy? A national survey of job satisfaction provides some unexpected results

by MICHAEL WOODHEAD

China's doctors have a lot to be unhappy about. Low pay, long hours, medical disputes that trigger abuse and violence from the public - and daft regulations that force them to publish a quota of 'scientific articles'  every year even when they have no interest in research. 

There has been a lot of talk about poor morale among China's medical profession in recent years, but very little actual research to back these claims up. To address this, the medical online portal DXY conducted a survey in September 2015 that asked a simple question: "do you regret becoming a doctor?"

Responses were obtained from 2,356 doctors, three quarters of whom were male and most were working in tertiary (teaching) hospitals in eastern China (not surprising given that DXY is a medical portal used predominantly by younger and more online-savvy medics).

The survey found that overall almost half of doctors (1146) said they had regrets about becoming a doctor. There was no significant difference between male and female doctors, but there were some interesting trends by speciality and location.

Emergency department doctors had by far the lowest morale, with almost three quarters regretting their choice of career. This is perhaps not surprising as emergency doctors are at the sharp end, doing exhausting shifts dealing with trauma - and being assaulted by stressed out patients and their families with complaints.  Other specialities with poor morale included paediatrics (low pay, high stress when dealing with pushy parents of ailing Little Emperors), obstetrics and gynaecology and oncology.

The specialities with the highest degree of job satisfaction (or least worst morale if you're a glass half empty person) were radiology, TCM and anaesthestics.  The survey also showed that community clinic physicians  also had less regret about medicine as a career - the study authors say this is presumably because they see less sick patients and are more likely to have an ongoing doctor-patient relationship in the community.

Interestingly, doctors in teaching hospitals tended to have better job satisfaction - possibly because the top hospitals have better career prospects and are more professionally stimulating. The doctors in the middle tier hospitals - level 2 - had the worse morale.

Trainee doctors and senior doctors also tended to have better morale whereas mid-career doctors in their 30s and 40s had the worst morale.

On a geographic basis, doctors in the more remote provinces such as Yunnan, Gansu, and Shanxi reported better morale. The survey authors said this was an unexpected results and suggested that salaries were not as important as once thought in job satisfaction.

The study authors say they now plan to publish a more in-depth analysis of the reasons given by the doctors for poor morale.

How an uneducated migrant worker became a successful medical journal editor: the publish-for-promotion swindle

 by Michael Woodhead
An amazing and hilarious story in the Chinese Legal Daily this week about how a rural migrant came to Beijing and set up a fake medical journal to publish scholarly articles for senior doctors wanting to boost their promotion prospects.

The young man ran a highly successful publishing operation and made almost two million yuan ($325,000) between 2009 and 2013 when his operation was busted by police. The man called Liu Yang was only 23 years old when he came to Beijing and started working on the reception desk of a hotel in 2009. It was while he was talking to a doctor at the hotel that he hit on his money-spinning idea. The doctor was complaining about how difficult it was to get promotion because of the requirement to have a quota of articles published in medical journals. The problem, he said, was simply that there were too many doctors trying to get published and not enough journals.

Liu Yang had the obvious idea of inventing a medical journal to meet that demand. Despite having only a middle school education and knowing nothing about medicine, he quit his job at the hotel and borrowed  money to buy some basic publishing equipment such as a scanner and large printer. He installed this at his apartment, which would become his editorial office. However, his most important investment was 200 yuan for copies of the leading medical journals, whose style he copied. He also bought a list of top doctors and top hospitals around China.

Awarding himself a doctorate and appointing himself editor and publisher, Liu Yang then wrote to the hospitals on his list and offered the services of his medical journal for publishing. He was immediately inundated with manuscripts from mid-career doctors. As a police investigator later explained to the reporter, the medical career pathway in China is based on publication of scholarly articles for advancement. Promotion from hospital resident onwards is dependent on having a list of articles that have been published in journals. No publication, no promotion.

"Dr" Liu Yang received so many submissions he was rushed off his feet publishing his journals every month, and soon had to call in his wife and other family members to help out. The journals were only circulated to the doctors who had articles published in them. It was essentially vanity publishing. And yet, to maintain some credibility, Liu Yang even started to reject some manuscripts. The fake journal published articles from doctors all over China: the most frequent users were doctors seeking elevation to 'deputy director of department' level, a career step which required many published articles.

At first, the fake journal was a print operation, but doctors then started asking 'Editor' Liu Yang why their articles were not being published online. The fake editor then expanded his shanzai operation online and hired a web designer to copy the website  of a leading medical journal and set up a website for his own fake journal. Now Liu Yang offered digital journal publishing to his hundreds of clients.
In total he published articles by more than 800 doctors, and most were senior doctors at major hospitals, including military hospitals. Most did not realise the journal was a fake operation. A few suspected things were not quite above board, but still paid Liu Yang to publish their efforts because they believed others would not notice.

And for four years they didn't. As a police investigator remarked, there are hundreds of such medical articles and theses published every year and nobody is much interested in what they say - they are simply published to impress hospital administrators. And so until recently nobody was auditing these medical articles or the journals that published them.

However, somebody must have eventually twigged to Liu Yang's ruse. In September 2013 police came calling at the new expanded Chaoyang offices that Liu Yang had expanded into. As cops banged on the door, his wife tried to throw plastic bags of money out of the window, whereas Liu was more interested in trying to save the raw materials for his publishing operation. The police gained entry to the premises and shut down the publishing business, confiscating equipment and 600,000 yuan. Liu Yang and his wife were arrested by police and charged with fraud.

Commenting on the case, a senior doctor at a Beijing Hospital said the fake journal saga highlighted a major fault of the medical career system in China, namely the reliance on having papers published. The doctor said there was enormous pressure on doctors to publish, because promotion offered higher income through access to prescribing a wider variety of drugs. Doctors who were good clinicians but did not publish remained stuck on the lower rung of the hospital ranking and only treated large numbers of patients. Some hospitals even fined their doctors if they did not achieve a quota of published article, he said. And the doctor said the busted operation was not the only fake journal -  he still regularly received emails from dubious sources offering journal publishing services and also ghostwriting services.

Liu Yang's fake publishing operation is now smashed, but the publish-for-promotion system is still intact in China. And while doctors are under enormous pressure to publish, other loopholes will be exploited, corners cut and more scams like those of Liu Yang can be expected to occur.

Young Chinese doctors under pressure to publish

by Heng-Feng Yuan, Wei-Dong Xu,  Hai-Yan Hu, Second Military Medical University, Shanghai
In recent medical job fairs, most large hospitals in China have considered articles listed in the Science Citation Index (SCI) as a must or priority for candidates. SCI articles are also the key to a large bonus or rapid promotion. It seems that SCI articles are controlling the fate of young doctors in China, whose goal is to be a research superpower by 2020.

As young doctors, we feel under great pressure to publish. However, basic scientific research is difficult, being almost outside the scope of our profession, and clinical research requires long-term follow-up or large case numbers, which are not easy to achieve for a young doctor. In our graduate careers, many of our classmates spent a large amount of time in the laboratory doing unfamiliar experiments, just so that they could publish SCI articles. Even in the hospital, SCI articles are still an important indicator of success for a department or doctor. Is this really more important than clinical competence?

Such a requirement is unreasonable and completely unnecessary. Not only does the pressure to publish take up too much energy and time, with little professional help, it can also lead to an inappropriate medical atmosphere. Young doctors should be paying more attention to the accumulation of medical experience and improving their communication skills with patients. Academic articles are welcome, but they should be mainly for the purposes of communication, and should be non-mandatory and derived from clinical practice. Moreover, articles should not be distinguished simply by whether or not they are cited by SCI.

Young Chinese doctors are encountering more and more challenges. China's health-system reforms should remove the SCI article burden, and build up a healthy assessment mechanism for these doctors.

Source: Lancet

Medicine loses its appeal as a career in China

High pressure, low incomes and increasingly tense relationships with patients have sent medical workers' career satisfaction to a new low, research has found.
Not only are doctors unhappy with their jobs - they are discouraging their children from following in their footsteps.
"I used to strongly encourage my daughter to study medicine, but now I'm not sure about that, given the several cases (of injured and murdered doctors) in the last year-and-a-half," said Lu Hai, vice-director of the ophthalmology department of Tongren Hospital in Beijing, which is famous for its eye treatment.
In September 2011, a male patient slashed Xu Wen, a doctor in Tongren Hospital's otolaryngology department, three years after he sued the hospital. The patient had accused Xu, who operated on the patient in 2006 in an effort to cure his throat cancer, of failing to root out the tumor, which he believed could have been eliminated in the first surgery, thus leading to a relapse.
Xu was seriously wounded but survived. Nevertheless, a court sentenced Wang to 15 years in prison in April 2012.
In the latest serious case, a 62-year-old man killed a female doctor, Kang Hongqian, with an ax in North China's Tianjin on Nov 29, 2012.
The man went to the first hospital affiliated with Tianjin University of Traditional Chinese Medicine twice in 2011 to be treated for hemiplegy caused by a stroke, China Youth Daily reported.
The man was acting strangely, a doctor in the hospital told the newspaper, but said he couldn't remember any dispute between him and the hospital before the killing took place.
Han Baojie, a doctor in the hospital and Kang's former colleague, said he and many co-workers made up their minds not to allow their children to practice medicine after the case.
The Chinese Medical Doctor Association found that 78 percent of the 3,700 doctors it surveyed in March 2011 said they didn't want their children to study medicine, while in 2009, 62.5 percent of the 3,200 subjects surveyed expressed the same opinion.
In all the surveys conducted around the country in 2002, 2004, 2009 and 2011, the association found that the rate of doctors willing to see their children become medical students was dropping.
The lack of value and pride in the job was also evident in the fact that 96 percent of doctors surveyed in 2011 believed that their salary didn't match their labor.
"Being a doctor should be a job that elites aspire to," said Deng Liqiang, director of the association's legal affairs department, who was also in charge of the survey.
"However, the heavy workload and salaries that don't match the effort make many doctors feel that their job is not that decent. In Beijing, a top doctor can get up to only 300,000 yuan of legal income a year. But in most cases, their income ranges from 3,000 yuan to 8,000 yuan a month. On the other hand, there are doctors taking illegal money like bribes, but this kind of income doesn't make them feel more decent".
A doctor of 22 years, 45-year-old Lu, agreed.
"A resident in my department gets only 3,000 to 4,000 yuan a month," he said. "Top doctors in the department, such as me, get about 10,000 yuan a month."
Several outstanding young doctors in the department left in recent years because "they didn't see any hope", he said.
Yet the "especially heavy workload" that doctors believe should be worth more is not the only cause of their pressure.
More than 70 percent of those polled said that medical disputes and "too many expectations from patients" also add to their work pressure.
"Only one-third of diseases can be effectively treated by medical science, and sometimes it's hard to predict how a disease will develop," said Deng, who was a doctor in Henan for eight years. "However, sometimes medical disputes occur when patients and/or their families feel that the treatment doesn't meet their expectations."
A rule issued by the Supreme People's Court in 2001 stated that hospitals must provide evidence that proves they are not responsible for injury to patients if a patient sues for allegedly flawed treatment.
Though the rule was scrapped in 2010, "more and more people had already formed the stereotyped thinking that any dissatisfaction they feel about the treatment has something to do with the hospital, and that they will get compensation as long as they draw attention to their dissatisfaction," Deng said.
As a lawyer, Deng said he has seen different ways of drawing attention: Not just filing complaints and lawsuits, but brawling, stalking and threatening.
Deng Bingbin, an intern in a public hospital in Beijing, believed the high expectations comes from a lack of knowledge.
"Some regard paying for medical treatment as paying to get a cabbage in the market," she said.
"However, it is not cabbage. One cannot simply expect that their diseases will be cured as long as they pay for the treatment. One cannot purchase life and health."
"I hope the public can get more information about what doctors can do when they fall ill, which is limited. The most important thing is to take care of yourself and watch out for their own health," the intern added.
What's more, the inclination to blame the hospital has helped nurture some professional "hospital troublemakers", groups of people take advantage of the dissatisfaction of the patients and their family, the intern said.
"Because of them, sometimes in disputes, a hospital gives compensation even when there is nothing much to compensate for, in a compromise for peace. I rather fear that I will meet them when I begin to work as a doctor," said the 23-year-old, though she insisted that the medical disputes and even violent cases have not deterred her from pursuing her chosen career.
However, such cases have deterred some doctors from taking risks for their patients, said Lu Hai, of Tongren Hospital.
"Some doctors will not try to do better even when they can. When they feel they are not so sure of the treatment, they will push their patients away to another doctor or another hospital, even persuade them to give up treatment," he said.
"After these kinds of dispute and murders, even I feel the sometimes delicate and subconscious change in my attitude toward patients -like I can't persuade myself to be truly nice."
A survey conducted by five college students in Central China's Hunan province got similar results.
The Hunan Normal University survey, which polled 363 doctors in 19 hospitals in the province from July to September, found that 61 percent of doctors don't like their jobs.
"Some doctors I interviewed said that they used to love their career, but their sense of accomplishment has faded when medical disputes and violent cases in hospitals are reported frequently and patients become less trusting," said Tan Xin, a member of the team majoring in psychology.
Tan said the survey "overturned" her views about doctors, after seeing how their daily work goes.
"I used to be upset when doctors treated me coldly during a consultation, thinking it was unacceptable that I had to suffer their attitude. However, they were mentally stressed when they had only three minutes for each visiting patient, and it's impossible for them to answer all that a patient wants to know," she said.
"Yet a patient often wants to know more about his condition, and the cool attitudes and often cursory answers by doctors may well upset them."
This dissatisfaction among patients may in turn be vented out on doctors themselves, she added.
"I hope that the two sides can understand each other more," said Tan. "Doctors can smile more and be less cold, and patients can try to tolerate doctors because their work burden is really heavy."
Source: China Daily

Six out of ten Chinese doctors hate their jobs - survey

A survey conducted by a group of Hunan university students has given a sobering look at the attitudes of China’s doctors.
The study, conducted by 5 third-year students at Hunan Normal University, surveyed 363 doctors at 19 hospitals. Of those, 61 percent reported that they were unhappy with their profession. Middle-aged clinicians had the lowest levels of mental well-being, according to the survey, while women doctors were generally less satisfied than men.
Being a doctor in China is an increasingly dangerous job, and 92 percent of doctors surveyed described their work as involving "great risk." Earlier this spring, a series of patient attacks on hospital workers killed one doctor and left five others injured.
In 2006, the last year for which detailed records on patient-doctor violence was reported publicly […] the Chinese Ministry of Health stated that 5,519 medical personnel had been "injured" in disputes -- a substantial increase over previous years.
The China Daily cited an "official source" who said that in 2010, 17,000 violent incidents took place, affecting roughly 70 percent of all public hospitals in China.
Such attacks have often met with public indifference, and at times even approval, as doctors are increasingly seen as corrupt and indifferent, taking bribes and prescribing unnecessary procedures to supplement meagre incomes.
A report last August by the Beijing-based Health Times painted an even bleaker picture of the attitudes of China’s health professionals. 96 percent of doctors surveyed told the newspaper they were unsatisfied with their jobs, while 70 percent said they would not allow their children to enter the medical profession.
Over 50 percent said they would change jobs if given the chance.

Read more: Shanghaiist