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.

Web rumour of the day: doctor sued after helping woman give birth on train

by Michael Woodhead
One of Xinhua's top stories today is about a female doctor who helped a woman give birth on a train from Beijing to Nanjing and was then sued by the mother because the baby was injured. 
Amazing story, but it isn't true, according to Xinhua. The news agency says the whole story was concocted by a disaffected young man from Henan who spread the 'baseless rumour'  on Weixin and caused the legal authorities in Nanjing a lot of grief.
The story started on June 29 when a story went viral on Weixin, Weibo and QQ. It described the case of a female doctor called Li Qian of the Beijing Third People's Hospital, who was travelling to Nanjing by train. A woman on the train went into labour and Dr Li helped to deliver her baby and saved its life. However, during the birth the baby aspirated some amniotic fluid and had breathing difficulties which required treatment at a hospital in Nanjing. The mother sued the doctor for the treatment costs and was awarded 15,000 Yuan compensation by the Nanjing Peoples Intermediate Court.
When the story was posted online it was circulated by hundreds of thousands of' 'netizens'  and elicited thousands of negative comments directed at the stupidity of the Nanjing legal authorities. The following day the Nanjing city legal office became aware of the negative and untrue rumour and reported the matter to the police. They acted swiftly and the original post was traced to a young man in Henan called Shang Mo. The Xinhua article doesn't say who Shang Mo is or what he does for a living, but he was presumably a doctor as he was said to be unhappy about the lack of legal protection for doctors against frivolous and false litigation.
 The legal authorities apprehended the man and Xinhua said he would face 'appropriate punishment from the relevant authorities'. They also reminded netizens that they must act within the law when posting things online and must not 'cross the line' and post material that is illegal and untruthful such as baseless rumours.
Update: The SCMP has now covered this story but with a major difference - it says the perpetrator was motivated by frustration over the law that restricts doctors working at only one location. That is quite different from the report by Xinhua which states that he was angry that "the law did not give doctors sufficient protection" . Not sure why the SCMP has reported this way.

Husband wins 300,000 yuan compensation from Beijing hospital over wife's death from pneumonia

A Beijing man has won Y300,000  in compensation from the Harmony Hospital in Beijing after a four year legal battle over the death of his wife from complications of pneumonia. The man claimed that his wife had died following  a lung biopsy to investigate the cause of her breathing difficulties. He claimed 900,000 yuan in compensation for living expenses and funeral costs, and was initially 25,000 yuan settlement by the hospital, which denied responsibility for the death. However, the man appealed to a higher court and was awarded 300,000 yuan when the court found that hospital in providing follow up care to the 57-year old woman. The court heard that the woman had a chronic lung disease resembling asthma. and was admitted to the hospital for tests in May 2011. However, the tests were carried out by a junior doctor who ordered a biopsy which the husband claimed was not necessary to diagnose pneumonia. The court also accepted his claim that the follow-up care after the biopsy was lacking as the woman received little supervision and developed pneumothorax and died. The court found that the hospital did not make basic precautions such as doing a risk assessment on the patient for the procedure, or managing thoracic drainage competently. It also heard that the hospital had altered medical records to try cover up its malpractice, but the court did not accept the evidence for this.

Psychiatric hospital sued for detaining healthy woman

Huilongguan Hospital in Beijing was sued by a female engineer named Chen Dan for 200,000 yuan ($32,820) for infringement of liberty.

Chen had been taken to the mental hospital by her parents against her will. After spending three days in the inpatient wards, she was pronounced to be not ill. Chen said the hospital violated her rights by failing to conduct any psychiatric exam or diagnosis before admitting her.

The hospital has countersued Chen Dan for 200,000 yuan for damaging its public image. They argued that Chen's parents were responsible for checking her into the hospital, and that they had provided effective medical treatment. Because Chen has refused to accept mediation, the case is still pending.

Source: East China News Service

Child abuse a major cause of brain injuries in Chinese children

Falls and traffic accidents account for most cases of traumatic brain injury in Chinese children

by Michael Woodhead
More than one in twenty cases of serious head injury in Chinese children is cause by child abuse, a new study shows.
The first study to investigate the causes, characteristics and trends of pediatric traumatic brain injuries in China, conducted in 77 hospitals, found that falls were the leading cause of traumatic brain injuries for all ages but peaked at 2 years of age.
Other common causes were being struck by/against objects and traffic collisions, the study of 4200 cases of paediatric traumatic brain injury found. Boys were more likely to have brain injury than girls, accounting for 77% of injuries.
The proportion of traumatic brain injuries caused by traffic collisions ranged from 10% in children 0–2 years old to 19% in 3–6 year olds. Among the traumatic brain injury cases caused by traffic collisions, the largest proportions were among motor vehicle passengers, bicycle/tricycle riders, and motorcycle riders, and each of these categories accounted for about 20% of the crash-related TBIs in each age group.
There were 125 brain injures in 0–2 year olds (6% of all injuries in this age group) that were caused by suspected child abuse. Suspected child abuse was significantly more likely to occur in infants under one year of age.
"Traumatic brain injuries caused by child abuse warrant further research and government attention as a social and medical problem in China,"  conclude the researchers form the Wuhan Children’s Hospital in Hubei.
Due to the lack of any legal requirement for doctors to report suspected child abuse  it is very likely that brain injuries caused by child abuse were under-reported in the study., the researchers add.
"We could only report these cases as “suspected child abuse” because a systematic legal procedure for confirming suspected child abuse cases does not exist in China," they note.
Source: PLOS One

Australian-Chinese cardiac surgeon jailed in Beijing after business dispute

Dr Du Zhuying ran a blood plasma product company in China

by John Garnaut and Philip Wen
An Australian cardiac surgeon has been jailed in China after his local partner allegedly stripped him of the business he founded and listed it on the Nasdaq stock exchange.
The case of Du Zuying, who was a heart and lung transplant specialist at St Vincent’s Hospital and Melbourne’s Royal Children’s Hospital, is perhaps the most startling in a series of murky prosecutions of ethnic Chinese Australians since the 2009 arrest of the Rio Tinto executive Stern Hu.
The company Dr Du founded, China Biologic Products, supplies blood plasma products to Chinese hospitals and is now valued at just under $300 million.
Neither the Australian government nor Dr Du’s family were initially notified of his detention in what was the first of several apparent breaches of China’s procedural laws and treaty obligations with Australia.
The case highlights how China’s failure to develop a credible legal system is eroding faith in its  capital markets, preventing technological innovation and increasingly affecting actors well beyond China’s shores.
It also raises questions about whether Australian ministers and officials  are systematically discouraging publicity of politically awkward ‘‘consular’’ cases in China, contrary to the wishes of Australian detainees and the advice of Chinese lawyers and international experts.
Diplomats urged the Du family to exercise “extreme caution” before approaching the media. The case was   concealed from public view for nearly two years.
Dr Du was detained at Beijing’s Capital Airport on February 9, 2011, while waiting to board  a flight to Australia where he would see his wife, Gong Jinxiu, and twin sons Tommy and Bruce.
“I waited four or five hours at Sydney Airport after the signal board said the flight had landed,” said Tommy Du, a 30-year-old tax professional at a big  Australian company.
The family discovered his father had been detained through informal channels but did not receive official confirmation for nearly two weeks.
The family arrived in Australia in 1989 and obtained citizenship in the early 1990s.
Dr Du developed a new powdered form of blood plasma protein that he hoped would help alleviate an acute shortage of blood for emergency transfusions in poor areas of rural China, such as  Hunan province where he was born.
It might have been one of Australia’s most successful biotech ventures if not for a series of opaque transactions that transferred Dr Du’s majority shareholding into the hands of his Chinese business partners.
Dr Du’s Beijing lawyer, Huang Kaiguo, says he is acting without payment because he is appalled at the treatment of “a great scientist” who has developed technology “that can benefit humanity”.
“This is the most miserable case I’ve come across in 10 years as a lawyer,” he said.
Read more: Sydney Morning Herald