Three vastly different articles on medical disputes - which one gets closest to the truth?

by MICHAEL WOODHEAD
Violent and disruptive medical disputes have become so common in China that they barely rate a mention in the media any more. There has to be something quite different about an attack on doctors for it to make the headlines these days. The recent incident in which a mob of disgruntled relatives of a former patient took over a Shenzhen hospital and forced doctors to kowtow to a 'shrine' was one such incident.

In response, the Chinese authorities have said they will now adopt a new zero-tolerance approach to such protests and attacks on healthcare staff.

"Vice Public Security Minister Huang Ming said police will crack down on hospital-related crimes and show zero tolerance to perpetrators who assault and injure medical personnel. He made the remarks at a meeting on safeguarding order at hospitals and promoting harmonious doctor-patient relations on Thursday."

Ho hum - we've heard it all before. Every time there is a violent attack on hospital staff there are pledges to crack down, strike hard etc etc. A few weeks later it is business as usual. As I've written on this blog before, nothing will change until the government addresses underlying reasons for these disputes: under-resourcing of hospitals leading to ridiculously high throughput of patients - 3 minute consultations in which patients are barely listened to and prescribed the most expensive treatments (so that the hospital can get a bigger profit).

According to the latest empty promise to 'take action' the minister Huang "ordered better settlement of medical disputes by taking precautions, conducting risk assessment and spotting and containing disputes at an early stage." Gee thanks.

The article also makes the implausible claim that the number of hospital-related cases of violence continued has fallen four years in a row, and is down 12.7 percent year on year. The reality is quite the opposite.

And while on the subject of propaganda, the Hong Kong based SCMP, always keen to peddle a  more palatable version of Beijing's policies to foreigners, this week has an interview with a doctor who believes the answer to medical disputes is in looking to China's history. In a Q&A article, journalist Zhuang Ping throws a few easy questions to Dr Yang Zhen, a surgeon and deputy chief of the hospital administration office in Shanghai’s Zhongshan Hospital.

Dr Yang says China should take a look at how doctors in China traditionally established good relations with patients. Other than a few glib statements about being nice to patients and showing a more human face, he doesn't explain how doctors will make this happen when they have to rush through 80-120 patients in one short shift ( and prescribe enough drugs to them to hit their salary bonus target). All pretty worthy sounding but meaningless, really.

The article with the greatest insight into China's medical disputes in published in an academic journal (Health Economics, Policy and Law) and is based on interviews with 12 doctors from a multitude of specialties working in Shenzhen.

Interestingly, the article starts off by directly contradicting the claims of the public security minister,  quoting figures from the China Hospital Association showing that the number of medical disputes has increased by about 20% a year.

"Once worshiped as ‘angels in white,’ members of the medical profession in China are facing unprecedented challenges. Due to the deteriorated public trust during the marketisation reforms of the last three decades, Chinese physicians are working in an antagonistic environment. Heavy workload, low remuneration, and tainted social prestige have left millions of physicians feeling undervalued and
made medicine a career to be avoided, a situation rarely seen in other Confucian societies," it notes.

The article makes several points about medical disputes that have been raised before - but also includes one new one that is unique and potentially game changing.

The authors say that whatever the causes, medical disputes are rarely settled through legal channels, despite there being an officially recommended dispute resolution pathway and laws that in theory should cover medicolegal areas of dispute. The reality is that patients and their families have found that they are much more likely to get results - and get them much faster - if they take matters into their own hands. In other words, mob rule. According to the article, aggrieved patients and relatives of those affected by medical misadventure have found that they can get financial compensation and see their grievances gain attention if they take violent and disruptive action against hospitals and their staff. In practice this means staging demonstrations, blockading departments - and even whole hospitals - and threatening staff. They do it because it works.

This is the testimony of one of the doctors interviewed:

"Because the macro political environment attaches paramount importance to the so-called
‘maintenance of social stability,’ hospital managers are very afraid of high-profile incidents because local government may blame them for failing to mitigate the tension. If payment can quench patients’ anger, hospital managers would certainly love to do that, even when the patients are obviously blackmailing them. Patients also know the hospitals’ mentality very well, and actually take advantage of it. Some have chosen to stage farcical protests because doing so best maximized their interests. In fact, they deliberately avoided legal resolution because they knew hospitals would satisfy their monetary demands anyway."

The article goes on to say that hospitals fear high-profile protests because of the detrimental impact on their reputation, (which would inevitably affect their income) and also the political mandate imposed by local government to avoid mass incidents.

"They are also generally reluctant to resort to legal channels as litigation will not only ruin their reputation, but also consume a great deal of energy and time. Many studies have identified private settlement as the most popular means of resolution, even when patients’ complaints are clearly
unreasonable," it says.

In a second part of the study, two thirds of 300 doctors surveyed described relations with patients as 'very tense' and a similar proportion (65%) had been physically assaulted at least in the previous year.

The authors of the study say there are several key lessons for preventing and managing medical disputes in China. First and foremost is the need to reduced doctors' workload to a level where they have time to interact with patients and spend a meaningful amount of time with patients to allow good communication, adequate assessment and diagnosis and explanation of medical matters so that patients can make 'informed choices'.

Secondly, there is an urgent need to remove the profit/bonus incentives for doctors so that they paid according to their performance on good clinical practice rather than on how many drugs they have prescribed.

The study authors have a rather bleak outlook about the possibility of curbing attacks on healthcare staff - at least in the short-to-medium turn:

"For decades, health policy reform proposals have always put financing reforms, realignment of provider incentives, or organizational restructuring first. However, the [medical dispute] crisis in China shows policymakers and advisors the detrimental consequences of hostile interactions between doctors and patients. While it is not unreasonable to expect systemic reforms to restore trust between the two parties, one must bear in mind that it may take much longer than anticipated to see the effects; in the meantime, the dysfunctional doctor–patient relationship continues to deteriorate," they conclude.

Hospital gangster siege reveals the murky side of China's healthcare management

by MICHAEL WOODHEAD
The bizarre 22-day occupation by mobsters of a hospital in Zhengzhou, Henan, is a revealing example of the murky finances and power arrangements behind China's hospitals. 

In late December almost 100 unidentified men invaded the Zhengzhou Meixin Chinese Medicine Hospital and disrupted its operations for more than three weeks. According to Chinese media, the men  - many wearing masks - obstructed the lobby, harrassed medical staff, put up banners and drove patients away. The hospital was thus put under siege by local thugs who stayed in the building playing cards and intimidating anyone who entered.

However, this was not the result of a medical dispute by aggrieved family members of a sick patient, but an extortion attempt to try recoup huge unpaid debts owed by the hospital manager, Wang Guangyu. According to Chinese media reports, the mob had been sent in to force Wang to make good on 17 million RMB funds that he owed to a distant relative, Li Jing. Her husband had previously invested more than 40 million in the hospital via Wang Guanyu, but after the husband died last year, the funds were not repaid in full. After several rebuffs, Li Jing called in the rest of her family to put some muscle on Wang.

In any other country a dispute like this would be settled by the police and the civil courts. However in Henan, amazingly, the ringleader of the occupation gang, Guo Zhiyang, was himself the leader of the local justice department and a former senior policeman.

For someone who is supposed to be upholding the rule of law, Gui Zhiyong appears to be a pretty lawless and criminal character. During his occupation of the hospital staff were threatened by men bearing knives and poles. One pregnant member of staff was so terrorised that she went into premature labour.

The incident ended on 9 Feb after provincial media became interested. When outside journalists first visited the hospital they were rebuffed, but were able to make some reports and take pictures. When this made the news beyond Zhengzhou, the occupiers slipped away, leaving the hospital deserted.

Guo Zhiyong could not be found but he issued statements saying he had been trying in a reasonable and lawful manner to handle personal matters with family. He accused the media of slander through their portrayal of him as a gangster and said he would take appropriate action to defend his reputation.

The whole saga may be an instructive lesson for any foreign companies contemplating running a hospital in China!

[Note: this incident is also reported by a "Gloria Chan" of the SCMP . However, the article so sanitised and anodyne as to be incomprehensible. Presumably this is the SCMP's way of trying to please the Chinese government by not washing China's dirty linen in public.]

Hospitals heed Xi Jinping's call to make use of "social capital", then rip off investors

by MICHAEL WOODHEAD
One of the cornerstones of Xi Jinping's healthcare reforms is the urging of public hospitals to take advantage of "social capital" (ie private investors) for future expansion and development.

Unfortunately, in China's murky and non-transparent climate of investment, things are quickly going wrong in predictable ways. A hospital in Jiangsu now owes its mom and pop investor almost a billion yuan, according to reports in the People's Daily. The Workers Hospital of Suqian asked locals and employees to put their capital into the hospital's investment fund and promised regular interest and dividend payments.

In 2012, a man called Chen heeded the call to invest in the Suqian hospital to help fund the building of a new hospital and to further develop and expand medical services. The hospital guaranteed a fixed income and this was backed by the local government. Mr Chen put in his 2 million yuan retirement savings and was initially  pleased with the interest payments he received on a regular monthly basis. In fact, Mr Chen was so impressed he persuaded his family and friends to invest their money in the hospital as well. In addition, local TV advertising that was aired to promote the fund resulted in more than 2000 small time investors putting close to 900 million yuan into the Worker's Hospital Investment Fund. However, things started to go wrong in April this year when the hospital defaulted on its interest payments. Investors who asked why they hadn't received their usual payments were fobbed off with non-commital replies.

However, as public complaints and protests increased, the local police and authorities have opened a financial investigation into the missing monies. So far they have found that there is not enough money to pay the interest and also not enough to repay the principal sums that were invested and which most investors are now demanding be repaid.

Several of the hospital financial managers have been detained for further investigation and the local authorities say they are now tracking a number of unauthorised financial investments. It looks very much like the Suqian people have had their social capital blown on the roller coaster Chinese stock market that crashed so spectacularly this year.

Putian cartel?

Meanwhile, China's private hospital market has started to take off in a big way with more than 8000 hospitals and clinics in the loose "Putian Network" forming an procurement alliance. The Putian hospitals network is a loose association of healthcare establishments set up from the 1980s onwards by entrepreneurial families from the Fujian town of the same name. Although suffering from a poor reputation for marketing of dodgy services such as fertility clinics and cosmetic centres, many of the Putian hospitals are trying to transition into more respectable establishments. Several of the hospitals have formed groupings and sought investors through IPOs. Now the Putian group hospitals say they are seeking to consolidate and form buyer's groups to give themselves greater purchasing clout. However, Putian hospital are still suffering from a credibility after being banned from Baidu for their dodgy advertising claims.

Starlet snubbed; swears at surgeon

by MICHAEL WOODHEAD
The Chinese public's dissatisfaction with the offhand and uncaring medical treatment they receive in state-owned hospital extends even to celebs. The China tabloids are today running the sensational gossip story of how singer and  Journey to the West star Han Xue (韩雪) lost her temper and screamed at a doctor who she was seeing at a Shanghai hospital for conjunctivitis.

The star has since apologised after her outburst hit the headlines, writing a piece on her Weibo blog about how the doctor treated her in a rude and offhand manner and refused to listen to her questions.

According to Han, she went to see a doctor at the Songjiang Branch Shanghai First People's Hospital after she developed a red eye from working underwater in a swimming pool as part of a film shoot. She got a ticket and waited in line like everyone else, only to be dismissed after just a cursory examination when she finally got a few minutes with a doctor.

Han Xue said the female doctor's attitude was indifferent and impatient, as she refused to even listen to her explanation of the eye problem. After a brief look at her eye the doctor wrote a prescription without saying anything to her.

When Han Xue remonstrated with the doctor, saying that she wanted a proper examination of what the problem was, the doctor merely replied that she didn't need to ask questions and could assess everything by sight. The doctor said she was busy and didn't not have time to waste. After being given a prescription and dismissed, Han Xue asked what the diagnosis was. The doctor simply said it was not a bacterial infection. When Han Xue complained about the lack of information and how the way she was treated was insensitive, the doctor said she was not a psychiatrist and didn't have time for niceties with a 'trivial' complaint like conjunctivitis. Han Xue retorted that her eye problem was not trivial to her, and that the doctor had a poor and unprofessional attitude.

The doctor said she didn't care, and this prompted Han Xue to 'lose it' and let out a stream of foul abuse at her. During the rant, the starlet asked the doctor whether she had been bullied as a child, and whether she had lost money on the Shanghai stockmarket crash. Shen finished with a shout that the doctor certainly did not deserve the title "Angel in a White Coat" (often applied in Chinese media to selfless medical staff).

On her blog, Han Xue apologised to the public for losing her temper and using bad language, but said she still stood by her judgement of the doctor as "uncaring and irresponsible" .

In the same week, Shanghai media have reported three separate physical attacks on hospital staff by irate patients and their families.

Bound feet, pirate hospitals and frequent flyer patients: just some of the medical news stories out of China this week

Bound feet not all bad for bones

Women who had their feet bound according to feudal Chinese tradition are more prone to osteoprosis but their enhanced balance skills mean they do not have excessive fractures, a study has found. A review of more than 250 elderly women who had bound feet by researchers at Kunming Medical University found that they had higher rates of osteoprosis than women of similar age.
However they did not seem to be in worse health or be more prone to fractures, the study found.
"This might be explained by compensation in physical activity to improve body balance, implying the importance of improving or maintaining body balance in overall prevention strategies against fragility fractures," the researchers said.

Trademarks use to fight pirate hospitals 

The renowned Beijing Tianlun fertility hospital has trademarked its name after finding that other hospitals around China were setting up 'Tianlun' fertility clinics and claiming to be affiliated to the famous clinic.

Frequent flyer patient

A Jiangxi endocrinologist has been called to provide emergency inflight medical help to the same woman twice in a month, according to CAAC News. The doctor treated the women on a flight to Thailand after she fainted. On the return flight he again answered a call for help and found he was helping the same woman with the same problem.

More family doctors for Henan

The Henan government claims to have re-trained almost 10,000 doctors to work as family doctors in community clinics and township-level hospitals. The government said the re-training program meant that Henan could not make family doctors available to 60% of people in rural areas and 100% of people in urban areas.

 Guangdong gets locals to sign up for GP cover

The Guangdong city of Huizhou says it has  got 30% of target patient populations to enrol with a family doctor. The city health authorities want to arrange GP cover for children under five, pregnant women, the elderly and people with chronic diseases. The authorities say they aim to have 50% of people enrolled by the end of the year.

Tianjin hospital gets Dr Weixin

A hospital in Tianjin has set up a smartphone service to allow patients to get advice, information  and book appointments via their phones. However, users said the electronic hospital system was clunky, did not allow access to many departments and they still had to queue to pay for appointments

Serious disease insurance cover to be nationwide.

China's minister for social security has said that his department will fully introduce nationwide social medical insurance for serious diseases within the year. However, critics have saod that hospitals will use the cover to claim rebates for unneccessary treatments while local governments will not have the finances to support the scheme. Meanwhile a group from Renmin University in Beijing have suggested that micro-credit schemes be used to give poor rural people access to funds to pay for their medical bills. The scheme would operate in the same way as micro-credit programs running in developing countries to provides funds for business startups.

Family planning staff become child development aides

The staff of local family planning departments may move into child development work and away from enforcing the single child policy, if a pilot program in Shaanxi is successful. The program sees family planing agency staff assisgned to follow up children up to the age of three to ensure they are meeting basic development goals in care and education, according to Caixin.


And this week's violence against healthcare workers:

Zhejiang: An armed man opened fire in a Zhejiang hospital and had to be disarmed by police after he injured one man and threatened patients and staff in the Haiyang country hospital.

Shanghai: A drunk man took a hostage at knifepoint at the emergency department of Shanghai No. 9 People’s hospital yesterday morning and injured a policeman who intervened.

Hebei: a  gang armed with machetes smashed up the emergency department of Baoding Hospital and severed the hand of a man who was being treated for minor injuries from an earlier attack. The man had been involved in an earlier altercation with the gang and they had come for payback, police said.

Liuzhou: a man got 10 days administrative detention and was fined 200 yuan for attacking a female doctor at a Liuzhou hospital. The man hit the female doctor because he was unhappy with the treatment his father was receiving for a bladder problem.

Beijing: A patient with a grudge over hand surgery assaulted a surgeon at the Jishuitan Hospital. The patient had previously had eight stitches in his  finger and was unhappy because it did not bend the way it did before the injury.

Why Chinese patients are turning against their doctors: contrasting articles by the New Yorker and BMJ

by Michael Woodhead
Two very interesting and very different articles this week on violence against doctors in China: one in the New Yorker and another in the form of a study in the BMJ Open. 

The New Yorker story is in the usual stylish narrative, but I prefer the BMJ Open article, because it has more facts and more insights, even if it is a dry scientific paper. In the New Yorker, writer Chris Beam uses the example of the murder of a doctor in Harbin to shine some light on the whole fraught situation of violence against doctors in China. The story focuses on the case of a young man from a small town who had debilitating and degenerative back pain (ankylosing spondylitis) and who was unable to get satisfactory treatment from a Harbin hospital. He also had TB, which made treatment with an immunosuppressive drug even more difficult. Frustrated at his patchy and expensive treatment, the young man returned to the hospital and attacked the first doctor he could find, and killed an 'innocent' medical practitioner who had nothing to do with his care.

Chris Beam tells the story well and uses it to give some background on the health system in China and why so many patients and their families turn violent when they are treated so badly. However, I found the article was a bit too focused on the legal side of things (the American obsession with law once again?) The article doesn't really explore the root causes of violence: the built-in pressure in the system to overprescribe and over service, the rising cost of treatment and the hugely overloaded hospital system. Beam does cover China's health reforms, but strangely fails to mention the recent moves to encourage private clinics and the use of primary care clinics.

Another factor not really touched on by the New Yorker article is the patient/family faults: for me some of the key factors in China's medical disputes are rising expectations combined with ignorance (poor health literacy) and readiness to use brute force. This is not just confined to health: see how Chinese travellers behave when flights are cancelled or hotel rooms are overbooked.

That's why I prefer the BMJ Open article by Dr Jiang Yishi and colleagues at the School of Public Health, Fudan University, Shanghai. Their article takes a look at the reality of the complaints systems that exist in Chinese hospitals - and finds them sadly wanting. Dr Jiang and colleagues undertook the first in-depth study of how the complaints system works for patients and for doctors and hospital staff. They conducted interviews with all 'stakeholders' and found that in many cases, the system is broken. In theory, a patient with a grievance has several channels through which they can seek redress. They can make a formal complaint to the hospital complaints office and can also petition via a system of 'letters and visits'. Patients can also go to mediation by a third party office to settle an unresolved dispute with a hospitals. And patients can also take legal action against a hospital via  a lawsuit.

In practice, these systems often do not work. Firstly, many patients are simply unaware of the complaints system and how to use it. Hospitals don't advertise their complaints offices, which are often hidden away in an obscure corner of the building. The staff in these offices are supposed to be able to investigate complaints and arrange mediation - but in practice they are often unqualified to adjudicate on complicated clinical matters, and they are also under great pressure to deflect complaints - or dismiss them quickly. Complaints departments are understaffed and have little sway in the hospital system. Another problem with the 'complaints office' system is that it lacks transparency. Patients make complaints but they get little feedback from complaints office staff who do everything 'behind closed doors'.

On the other hand, hospitals and medical staff also express great frustration about the complaints system. Doctors say any complaints arise because they work under great pressure to see 60 or more patients in a morning and don't have time to put on a 'warm face' or to explain things in detail to patients. This lack of connection and communication leads to many misunderstandings and unhappy patients.  Doctors also say that they become the scapegoat for failings of the system: for example, (just as in the US) they are restricted in what treatments they can offer to patients by the medical insurance rules - but patients don't understand this and often get angry at being denied treatments are given treatments that come with a hefty out of pocket costs.

Another big frustration for doctors and hospitals is the rise in unreasonable complaints and the use of abuse and pressure (extortion) to get a complaint resolved with financial compensation. More than 50 doctors interviewed mentioned this 'chao' (吵, argue) phenomenon. Doctors said many patients and relatives had unrealistic expectations about what could be done by medical staff. And when things didn't have a good outcome, patients and relatives often turned to threats and 'mob tactics' to put pressure on doctors and hospitals. These unruly groups are not interested in facts or a fair settlement but want to cause as much trouble as is needed to get a financial payout.

The BMJ Open article says the whole health complaints system in China is lacking in structure and rigour: there are no standard protocols for investigating complaints, for assessing harm and no data is collected on complaint numbers or how they are followed up - and no system for using complaints to identify weaknesses or errors and give feedback accordingly. Hospitals have no incentive to collect or document complaints because it just gives them more 'black marks'. 

The overall impression of the health complaints system is that it is perfunctory and ineffective: hospital directors want complaints to be managed quickly and made to 'go away', hence the readiness to make a quick financial settlement and avoid trouble and bad publicity, especially when angry mobs are involved.

The article by Jiang concludes by identifying three crucial areas where improvement is needed in the complaints system: organisational support, personal support from hospital managers and political leaders (and patients) - and learning system to ensure that failures are identified and rectified. The solutions put forward are sensible and obvious - and the full paper is well worth a read. 

However, I  would not be optimistic about the prospects for change: many of the problems that plague the health complaints system are common to those of Chinese society in general: there is a lack of trust in institutions (in this case hospitals and health departments) which are not accountable, lack transparency and which combine vested financial interest with political power. The solutions require open-ness, accountability and an independent watchdog with teeth. In the current environment in China, those are not likely to happen. Instead, China has top-down directives to crack down on the symptoms of these failings - the government issues stern warnings and makes some highly public arrests of wrongdoers. Ultimately it will take workable systems to fix the problems of health grievances, not campaigns and punishments.

Hunan: 200 hospital staff strike and stage protest over attack

by Michael Woodhead
More than 200 hospital staff staged a sudden strike and protest at the Yueyang Second Hospital after medical staff were attacked, held hostage and forced to kneel in front of the body of a patient.

The incident arose after a young man was brought into the hospital emergency department on August 20th with stab wounds. The patient, a 31-year old male called Chen Qiming, was critically ill and did not survive for long. After his death, dozens of relatives of the dead man came into the hospital and created havoc, seizing and beating medical staff and forcing them to kneel in front of the body of their dead relative in the mortuary. The family members also ran riot in the hospital, smashing up offices and blocking entrances, disrupting normal working of the hospital for eight hours.

The next morning hospital staff said they would refuse to work until those responsible for the attacks had been brought to justice and they were provided with adequate safety protection in the workplace.
They carried placards saying "Expecting fairness, give us respect". The protest attracted a large crowd of onlookers, and the strikers said they demanded that their legal rights be respected.

A staff member at the hospital said the mood of staff was indignant and emotional.  Hospital managers had advised them not to stage a protest but to instead take their grievances to the local government office. However, the staff opted for a spontaneous strike and could not be blocked.

Doctors said the dead man had suffered critical injuries including deep penetrating knife wounds to the chest that caused heavy blood loss and which were not survivable. They had done everything they could to save him when he was brought into the hospital, but despite their best efforts the man died.
When the staff were attacked many other staff members including doctors and ambulance drivers came to their help, and police were called. However, despite trying to mediate, the more than 150 police were unable to settle the situation for eight hours.

A spokesman for the Yueyang City Health Bureau said an investigation had been launched into the incident. Local police said they were also investigating the incident but had not yet contacted the families said to have been involved in the attacks.

According to sources at the hospital this is the second violent attack on staff this year and the third violent medical dispute in Hunan in in the last two months.

Police set up 'safe rooms' in 90% of Henan hospitals

Setting up police-supervised safe rooms  has helped curb three major problems in Henan hospitals: violent attacks against staff, organised gangs of scalpers and theft.

The 'independent police service rooms' have been set up primarily to provide a place where frustrated patients can have their grievances attended to without them posing a physical risk of assault to hospital staff. According to CNTV, the rooms are staffed by police with protective gear and the rooms are equipped with panic buttons and camera surveillance equipment in case things get out of hand when emotions run high between doctors and patients.

The police presence also helps to curb the presence of organised gangs of scalpers who lurk around hospitals, selling registration tickets that help those with money jump the queue and avoid waits of many hours to get in to see a doctor. These same gangs also use their 'muscle' to intimidate staff on behalf of aggrieved families in an attempt to extort compensation - from which they take their cut.

"We feel a lot safer now. It provides an open platform for us to communicate with the patients, and it helps us solve medical disputes. Also, there's been less theft,"  said a senior doctor at a hospital in Zhengzhou that had installed a police room.

After a series of high profile assaults and killings of medical staff in recent months, China has increased penalties for violent disputes against health workers. There have also been reports of riot police being brought into hospitals. However, doctors say the root causes of the problem have not been - an overloaded hospital system in which patients wait hours to see a doctor and then only get a few minutes before being over-prescribed medicines with high markups.

Chinese doctors not happy at rating lists made by patients

by Michael Woodhead
Are you on the Medical Honour Roll or the Black List?
That's the question being asked by doctors in Guangzhou over the websites and social media forums that categorise doctors in the city according to a 'red list' (Honour Roll) or black list. The widely circulated lists ask members of the public to rate doctors according to these criteria:

Black List: 
Attitude: cold and aloof
Orders a lot of tests, prescribes a lot of drugs 
Recommends lots of nutritional supplements

Red List
Good demenour, attentive
Patient
Willing to explain
Not an overprescriber

The lists of doctors at 15 of the city's hospitals have been circulated widely on forums such as Weibo and Weixin, but health authorities claim that they are subjective and un-scientific, and will lead to increased tension and disputes between doctors and patients. They are calling on Guangzhou residents not to circulate or contribute such misleading unofficial lists. They have noted that there are many insulting and coarse comments about the doctors on the Black List, but the doctors named have no right to reply or to correct the statements made about them.

The Black and Red lists also allow users to add their own experiences. One women who claimed to be a patient at a maternity hospital said the named doctor did not even let her finish speaking before writing a prescription and asking to see the next patient. Another said the doctor barely listened to her, ordered 1000 yuan of tests and when she said she didn't have the money to pay for them, simply threw the forms in the bin.

A common refrain on the doctor rating forum sites is that it is impossible to find a sympathetic doctor who is easy to see without a long waiting time or guangxi.

However, the deputy director of one of the city hospitals told reporters that these assessments of a doctor's capability were subjective, unverified and often taken out of context. He said the Red List and Black List did not reflect the clinical skills and experience of the doctors named on the lists. All senior doctors working at the city hospitals had to study for many years, pass many exams and were also evaluated by their peers before gaining promotion, he said. Doctors who were incompetent or who practised bad medicine were not tolerated within the public hospitals system, he said.

The hospital director said patients often got a false impression of doctors because their encounters were superficial and they often had to wait for a long time to see them, hence they had a sense of grievance. The comments did not reflect the pressure under which doctors work he said. Also, many of the comments were about the 'service attitude' of the doctors, which did not reflect their medical skills, he said. He compared the 'doctor rating' sites to theatre reviewers - two people can see the same performance and one will hate it while another thinks it is good.

Another deputy director at a vascular hospitals said the lists were meaningless and some even had the same doctors on both red and black lists. Individual opinions varied, he said, and he used the saying "one man's meat is another man's poison" to show that some patients would find a doctor to be 'good' while others would find them to be 'bad'.

Health authorities recommended that consumers use the "Third Party" healthcare service  evaluation site. This invites feedback for healthcare consumers, but the information is checked and verified by independent professional before being added to the website. The Third Party site also follows up claims of problems such as overcharging and overservicing and will contact the patient and the service provider to provide feedback and improve the service, the health authorities said.

Doctor taken hostage after patient dies of lung cancer

by Michael Woodhead
An oncologist was taken hostage by a knife-wielding man at a Dongguan hospital after the man's father died from lung cancer, Guangdong media have reported.
The doctor, surnamed Chang, was able to escape from his captor during negotiations with police, but two police were injured while trying to apprehend the hijacker. Doctors say the man was the son of a patient who died after an operation for lung cancer on 9th May. Doctors said the patient had been unco-operative throughout his treatment and had refused to follow doctor's advice, even refusing to stay in bed when he was sick. When the man got out of bed and started moving round, he had breathing difficulties and his condition deteriorated and he collapsed. After the man died, his son left and returned with a knife, which he used to threaten staff, and he took Dr Chang hostage and locked the door. He called for Dr Wen to come over, believing him to be the one responsible for his father's death and said he would kill him and then himself. Dr Chang told the man that he was the one who operated on his father and only he was responsible. When he tried calling for Dr Wen three times without success, the man got more agitated.
A police hostage squad with shields came to the hospital and started negotiations with the attacker, who had Dr Chen held with a knife at his neck. When the hostage negotiator asked the man to approach to talk, Dr Chen was able to suddenly break away and escape from the room. The attacker chased after the doctor but was stopped by police who used their shields to press him to the wall. When the attacker was trapped he lashed out at police with the knife, stabbing two of them around the ear and the hand, injuring them.
The 28-year old man was then arrested by police. Dr Chang said it was the first time in his career that he had ever come across such an extreme situation.

Can you legislate to make better doctors?

 
by Michael Woodhead
New draft legislation released by China's National Health and Family Planning Commission seeks to make doctors practise medicine in a more humane and 'patient-centred' way. The new regulations will make it a criminal offence for a doctor to neglect to treat a patient, and will force doctors to take responsibility for the adverse outcomes of any patient that they fail to treat in a reasonable and timely manner.
Released at the behest of the State Council, the "Medical Treatment Quality Management Regulations (Draft)" is a wide ranging document that aims to improve the quality of medical treatment by spelling out the doctor's duties and also highlighting prohibited practices.
The new rules state that it will be a criminal offence for medical staff to refuse to take responsibility for patients in need or treatment, and staff must bear the consequences of any damage or injury that results from failing to provide treatment. The NHFPC says the new legislation also requires health providers to have mechanisms in place to accept and respond to medical complaints in a timely manner. It says medical staff must act in a humane and patient-centred way to carry out the core responsibility of "healing the wounded and rescue the dying". Staff must show respect to the patient and uphold their rights. The new rules also require medical personnel to use medications responsibly and to have a good knowledge of how they work and their efficacy. They also make it a criminal offence to use non-approved drugs, medical procedures, equipment.

Six sick crimes: Supreme Court issues guidelines on how to manage violent medical disputes

by Michael Woodhead  
In response to a wave of attacks on doctors and nurses, China's Supreme Court has released a list of six illegal activities that will be targeted as part of guidelines on how to manage violent disputes in healthcare settings.
 The criminal activities highlighted are:

1. Attacking doctors and damaging hospital property,
2. Setting up shrines and burning paper money in medical institutions [Ed note: this is done to disrupt hospitals and extort money],
3. Restricting doctors' freedom (eg harassing doctors, blocking their movement)
4. Insulting medical workers,
5. Bringing weapons into medical institutions,
6. Instigating others (including family members) to commit crimes against medical staff.

Any violations of these guidelines will result in serious consequences, and offenders will be convicted and punished under criminal law, the Supreme Court has announced. The list is part of a new 'opinion" position statement drawn up by the Supreme People's Procurate, Ministry of Public Security, Ministry of Justice, National Health and Family Planning Commission jointly entitled "On the punishment of crimes involving medical advice, medical order and maintaining normal law". The new guidelines also call on medical institutions to prevent medical disputes by ensuring a good standard of medical care, enhance medical ethics, improve service attitudes, focus on humane care and to maintain good communication with patients. They also call on institutions to set up dispute mediation protocols to handle complaints and to offer adequate security to medical staff. "The Supreme People's Court will uphold the law while handling cases involving medical disputes and severely punish those who seriously harm or even kill doctors over groundless assumptions," said Sun Jungong, the spokesman of the Supreme Court. China had more than 50,000 serious medical disputes last year and two doctors were killed by disgruntled patients, drawing the death penalty for the offenders. The Supreme Court said disputes must be handled in a timely way and resolved by arbitration or through fast track medicolegal channels if necessary.

Africans face health discrimination in China | Cochlear implants success | Fake doctor operates on 1500 women | Psychiatrist says 10 words charges 1000 yuan fee

Africans in China face medical discrimination
With the growing economic links between China and Africa there are as many as 100,000 Africans in Guangzhou but they lack access to healthcare, an article in The Lancet this weeks says. Africans in China face racial discrimination, which fuels mental health problems and also is a barrier to them getting access to needed health services and support. Many Chinese people maintain stereotypes toward Africans viewing them as prone to violence and posing risks to public health through spreading diseases, the article says. While China sends medical teams to Africa, it ignores the Africans living within China.
"Providing Africans medical care is consistent with China's health-care reform, but the system has failed to close the treatment gap. Chinese doctors are not trained in culturally adapted care or in the management of specific diseases affecting Africans, and translation services are unavailable," the article concludes.

More Chinese medical tourists
Affluent Chinese are now seeking medical care overseas, according to CCTV. Their report says more Chinese are going to foreign countries for treatment and the trend is blamed on the lack of access to high quality clinics in China.

No takers for dispute insurance
Few people are choosing to take part in a new surgical insurance program that is designed to reduce medical disputes. The new medical insurance scheme pays only in the event of unsatisfactory results caused by medical malpractice not covered by traditional medical indemnity insurance.

Bionic ears work well in China
Cochlear implants have been used successfully in hundreds of Chinese deaf children and have had few complications, according to a new report from Henan. Cochlear implantation is a safe procedure and early postoperative complications are minor, say clinicians from the Department of Otology at the First Affiliated Hospital of Zhengzhou University.

Fake doctor did nearly 1500 operations
A bogus surgeon working at a gynaecology clinic in Henan performed 1485 operations on women and made almost half a million yuan in profit before being caught, Zhengzhou media report. The Pingdangshan court sentenced bogus doctor Ma Juan to nine years in prison and fined him 300,00 yuan for performing minimally invasive surgery on women at the Third Peoples Hospital gynaecology clinic. The manager of the clinic was also jailed for 12 years for employing the fake doctor and encouraging him to exaggerate illness and overtreat women with unnecessary but profitable operations such as cervical cauterisation and nerve blocks.

Psych clinic has few words of comfort
A Chongqing father has complained of extortionate charges and poor doctor-patient communication at a mental health clinic where he took his uncommunicative 'autistic' daughter for treatment. The man told the Chongqing Evening News that he had to pay almost 1000 yuan for antidepressant medicines after a brief consultation with a doctor who did not speak more than ten words to him or his daughter. The father sad the costs for the questionnaire test and brief consultation were excessive. A medical expert said mental health clinics were under a lot of time pressure and were not designed to provide psychotherapy but to treat psychiatric diseases. If patients want to talk more they should visit a psychologist, he suggested.

Defiant words of a doctor killer: Lian Enqing has no regrets for murdering surgeon he blamed for botched rhinoplasty

by Michael Woodhead
The 33-year man Lian Enqing found guilty of killing a Zhejiang doctor over failed nasal surgery has had his appeal against a death sentence turned down, but seems to have no regrets about what he did.
A lengthy article in Guangming Daily portrays faults throughout the system, including sub-standard medical treatment, shoddy hospital record keeping, a flawed medical dispute resolution system and a harsh legal system that condemns a mentally ill man to death. The article includes a few words from a CCTV interview with the murderer, Lian Enqing, from which it is apparent he is delusional and convinced that his victim got what he deserved.

The tragic case originated in March 2012 when the man sought medical help for a chronic sinusitis and nasal obstruction. He had ENT surgery for his problem at a Wenling hospital with surgeon Wang Yunjie, but after a few weeks it became obvious to the patient that the surgery had not relieved his problem - if anything, his symptoms became worse. He went back to the hospital and sought a review, but was not satisfied with the results of the tests. he went back many times to several different hospitals - including some in Shanghai - and underwent many investigations, including CT scans, all of which could find no explanation for his ongoing nasal symptoms and discomfort.

Lian Enqing refused to believe the results of the tests and became convinced that there was a conspiracy, and that doctors were covering up their mistakes. His belief was bolstered by shoddy record keeping at the hospitals, with some hospitals giving his the wrong results or imaging scans. Lian became more angry and assaulted members of his family. In July 2013 he scrawled a message about his surgeon on his wall saying "Wang Yunjie must die". He was taken by his family to a psychiatric hospital in Shanghai and diagnosed as having depression and delusional disorder and he spent some weeks in treatment.

However, his basic belief and resentment against the doctors did not change, and in October 25 2013 he went back to the hospital and attacked his surgeon Wang Yunjie with a knife, stabbing him to death and injuring other doctors. Eyewitnesses say this was no spur of the moment killing -Lian was determined, and even prevented other doctors from getting to the injured surgeon to try and save him.
 An interview aired on CCTV showed that Lian still believed there was a cover up of mistake,

Journalist: Most people would believe the results of multiple repeated tests - what was your reason for not believing them?

Lian: Because doctors feared being exposed. It would harm their image and their reputation to be shown to be wrong.

Journalist: Do you think doctors need to create such a big and complex set of lies over one pateint and one operation?

Lian: Yes

Q: But this would mean collusion on a grand scale, not just within the hospital but withing the region and even with doctors in the Fudan University Hospital in Shanghai Why would they all do that?

Journalist: Because it is a stain on the medical community, a dark stain.

The judge in the case said that he sympathised with Lian a little as his frustration and sense of injustice was justified because he had received sub-standard treatment and his complaint had not been handled properly. Nevertheless, nothing could excuse the extreme violent reaction to the unfortunate events that befell him, he added. Lian still did not acknowledge his crime or show any remorse.
In this situation, given what he did, the court had no alternative but to follow the law and conform the death sentence, he said.

The judge said that if doctors weren't so busy and if the hospital system wasn't under so much pressure, then such a tragic event may not have occurred. He urged doctors to improve the system
and be more understanding of the patients situation.

Doctor defamed online by spurned patient

A well respected ophthalmologist at a Chengdu hospital was slandered online by a patient who claimed that he was unethical and had discriminated against her daughter. In an 'exposure' on an online forum, the female patient said her daughter had been refused treatment by a Professor Liu, who discriminated against her because she was a single mother and yet he consented to treat other patients who were less deserving than her. On a popular social media site the woman said the professor had no ethics and she warned that he discriminated against common local people. The post stirred up a lot of angry debate about the ethics of the doctor.
However, when reporter from Sichuan Online followed up at the hospital he heard a very different story. The staff said the woman was impolite and demanded treatment despite not having registered at the hospital. Also she had no medical records and her case was not urgent. A patient from Yunnan was seen instead as their case was urgent and because they faced extra expenses if the case was delayed until the following morning.
Professor Liu said he personally intervened after the woman  argued with nurses. He said it was reasonable in a busy clinic to ask the woman to return when she had her medical records. The other case was more deserving. A security camera recorded the woman acting aggressively and knocking over billboards and items on a table in rage.
However, this story was not told online, and the social media site was led to believe that Professor Liu was an arrogant and uncaring doctor with no ethics. His name has been blackened. Nurses and staff at the hospital said he was a caring and hard-working doctor who often stayed until 9pm at night to ensure that all patients in the waiting room were treated.

My top10 medical stories from China for Saturday 22 February

1. Smoking with a water pipe confers a 'profound' risk of chronic obstructive pulmonary disease (COPD) among people in south west China and also carries a high risk from passive smoking, researchers have shown.

2. Patients with pneumonia of unexplained origin should be promptly investigated for H7N9 risk factors such as exposure to poultry and they should also be given pre-emptive antiviral treatment such as Tamiflu, the Beijing health department has ordered.

3. About 85% of Chinese doctors experience burnout, with those who are younger, unmarried and working in emergcncy medicine having the highest risk of serious burnout, a study shows.

4. Fertility clinics in China need to become more patient-friendly as they are perceived as too impersonal and lacking in transparency and respect for patient informed consent, researchers say.

5. The stigma of mental illness in Chinese culture means that patients with schizophrenia often do not understand their medication and are unwilling to take any anti-psychotic medication, according to a study from the Guangzhou Psychiatric Hospital.

6. H. Pylori infection rates are over 90% among people in their thirties in Jiangsu, which may explain high rates of gastric cancer in the region, say researchers from Nanjing.

7. Babies in Shenyang have increased rates of neurodevelopmental deficits because their mothers were exposed to high levels of organophosphorous pesticides during pregnancy, according to a study in PLOS One.

8. Adenovirus has emerged as a significant cause of serious pneumonia in China, with a study showing that 5% of cases are attributable to the virus.

9.  People with tuberculosis are also at high risk of HIV, with rates of around 3% in groups tested in TB patients from Guangxi, Henan and Sichuan, say Chinese researchers.

10. A mediation service for patients involved in medical disputes with hospitals is to be launched in Shanghai and it will be open to patients where compensation claims exceed 30,000 yuan ($2900) regardless of whether the hospital refers them.

Mianyang hospital doctors strike in protest against 'Corridor doctor' whistleblower

The long running saga of the Sichuan 'whistleblower doctor' took another twist this week as her colleagues staged a stop work meeting and mounted a noisy demonstration in Mianyang. They complained that the doctor's widely-aired allegations of overservicing and bad medical practice at the hospital were untrue and had besmirched their reputation. Police were called to the demonstration by medical staff as they became angry and shouted for her to be expelled from the hospital. They said the doctor's allegations had ruined the reputation of the hospital and resulted in it being downgraded, despite an official investigation finding no wrongdoing. Her allegations had also resulted in doctors at the hospital being abused and ridiculed, they said. Her claims of poor medical practice had stuck to individual members of staff who now found it hard to work because patients no longer trusted them, they added.  Dr Lan Yuefeng claimed to have been stood down from her position in the ultrasound department after she refused to agree to overtreatment of patients. She became a media star when she carried on working in a corridor for almost two years after being turned out of her office.

Doctor bludgeoned to death by "revenge killer" former patient angry over nose job

by Michael Woodhead
The head of the ENT department at Qiqihar Beigang Hospital in Heilongjiang has been bludgeoned to death by an 18-year old youth who was dissatisfied with the treatment he received from the doctor.
According to Chinese media reports the young man surnamed Qi entered the hospital brandishing a 50cm steel pipe, which he used to bash in the face of Dr Sun Dongtao. A doctor who witnessed the attack said the young man bashed Dr Sun so violently in the face and throat that he was not recognisable. Despite receiving immediate treatment the 45-year old doctor died. The suspect was apprehended by police, who found he was a local high school student who had recently undergone treatment on his nose by Dr Sun but was dissatisfied. Police said he developed a deep feeling of resentment against Dr Sun and sought revenge.

Family beat doctor and force him to kneel before dead patient's coffin

A medical dispute in Shaoxing took a bizarre turn when the relatives of a man who died of infection in hospital brought his coffin to the hospital and forced a doctor to kneel before it and kow-tow. The gang of family members then beat the doctor severely and also fought with police. Xinhua reports that the family brought the man into hospital suffering from a gallbladder complaint. He initially recovered slightly but then developed a severe infection and died. Family members blamed the hospital for his death and returned to hold a 'funeral' in the hospital reception area. The laid wreaths there and brought the coffin of their father. The family members caused a commotion, shouting and swearing, and they grabbed a doctor who they made to kneel down before the coffin for almost an hour. Then they beat the doctor so severely he required hospital treatment. The assailants also fought with police before they ran off. The incident has generated a lot of comment on social media sites, with some people saying they sympathise with the family but their violent actions were too much. Medical staff at the hospital are outraged and say the attackers must be caught and tried for their 'disgusting and brutal behaviour. Local law enforcement official shave told the family members to give themselves up.

Nanjing Hospital - lack of trust means doctors carry pepper spray and perform defensive medicine

Doctors in Nanjing say the complete breakdown in trust between hospitals and patients means that clinical staff now carry pepper spray for their own protection against attacks, and carry out many unnecessary tests just to protect their own back.
In an article in the Guangming Daily doctors say that in the 'old days' before a routine procedure such as an appendix removal doctors would simply have nurses prepare the patient and ask them if they were allergic to penicillin. Now staff have to routinely test all patients for infectious diseases such as syphilis and HIV because otherwise they fear being accused by pateints with these infections that they were picked up in hospital. These additional tests mean patients have to pay more money, adding to the dissatisfaction. Doctors say that patients and their families now query every single action and intervention by the doctors, making their lives miserable and prolonging consultation times.