CPPCC - what they're saying about health

It's that time of the year again - the Chinese People’s Political Consultative Conference (CPPCC). The toothless talking shop cum fancy dress parade as deputies from around China meet to chinwag and talk up the government's policies. It's an occasionally interesting forum - some grievances are allowed to be aired, but usually only to justify measures that are already being taken.
There has been quite a bit of talk about healthcare this year. Most of the problems discussed are ones that have been given a regular airing on this blog: doctors' income linked to overservicing, excessive workload of doctors and the issue of publish for promotion. On the last point, Prime minister Li Keqiang attended one meeting that heard about the problem of junior doctors having to publish academic papers in order to qualify for promotion. He was told that more than a quarter of doctors had their articles written for them by ghostwriters and agencies. The PM said this was a bad situation and doctor's should be rated on their practical skills, not writing skills.

Our old friend Professor Zhong Nanshan made an appearance at one People's Conference, at which he re-stated his concerns about doctors' pay being linked to sales of drugs and number of procedures and devices provided. He cited the case of one cardiologist who implanted several expensive cardiac stents for a patients who was not even seriously ill. Zhong Nanshan said the problem of doctors' ethic arose because up to 80% of their income was tied to hospital profits. This meant doctors were given quotas to meet and the 'profit-driven' mentality meant that hospitals were more like department stores than public health facilities, he said. Zhong Nanshan said that to end the problem of overservicing there was a need to de-link doctors' incomes from prescribing and servicing levels. Doctors should be paid a higher basic salary that reflected their worth, he said - and he stressed this did not mean a return to the 'iron rice bowl' mentality.

The problems caused by pharmaceutical commission were highlighted this week by the news that GSK is to sack 110 of its employees in China in the wake of last year's massive bribery scandal that resulted in the company being fined  $450 million. The widespread use of bribes, commissions and backhanders caused a lot of pain for the multinational pharma company when exposed. The staff who have lost their jobs may well be scapegoats. The man at the top, CEO Andrew Whitty, kept his job but had his salary package halved to a measly $6 million. Whitty said  “substantial changes” had been made at GSK China, including training for managers in anti-bribery and corruption practices.

Other 'unhealthy tendencies' raised at the CPPCC include the hospital VIP suites reserved for officials and local bigwigs. Professor Huang Zemin of East China Normal University said hospitals had two different worlds, with the VIP outpatient wards reserved for officials being quiet and luxurious whereas the outpatient room for the general public was crowded and noisy. A fair point, but the VIP suites have already been slated for abolition, so he's hardly breaking new ground there.

And also from the CPPCC, a cry for help from the paediatricians.  One of the country's top paediatricians, Professor Shu Xiaomei, told the CPPCC that there was a crisis in paediatrics as very few doctors go into this branch of medicine in China. The reasons are that paediatricians earn very little compared to other doctors, again because they don't prescribe so many drugs or do many procedures). Another reason for the unpopularity of paediatrics is the high workload and the huge pressure from pushy parents - often leading to violence when things go wrong. Professor Shu said there was also no formal training program for paediatrics, unlike other specialties and therefore the speciality was a 'tree without roots'.

The workforce theme was raised by another delegate at the CPPCC, who said that China simply does not have enough qualified doctors to do everything that the public expected of them. His succinct appraisal was that "without more doctors, all discussion about health reforms is empty talk. "
Other CPPCC delegates said that the push to create a primary care system based around community clinics was commendable but facing the major problem of neither doctors nor patients wanting to go anywhere near primary health clinics. Dr Zhao Ping, of the Chinese Academy of Medical Sciences, said patients did not go to local clinics because they had poor equipment and poorly trained staff and could not refer to the best specialists.
"People don't trust these clinics and hospitals. The thing is, people want to go to better and larger hospitals, and so do healthcare workers. We don't have a mechanism in-place to keep our best healthcare workers at community clinics," he said.

But it's not just the CPPCC, here are some other major medical news stories from China this week:

• Two doctors in their 20s have died suddenly of 'overwork' in the last few weeks, prompting some doctors to say that the pressure of work is too high.

• Baidu's CEO Robin Li says Baidu is looking at online appointment systems.

• China's first new advertising law in 20 years is expected to tighten up regulations around advertising of medical products and healthcare services .

• A Fuzhou doctor became a social media viral sensation when he was photographed working while hooked up to an IV infusion. Weibo users praised him for his dedication for working while sick. 

• International medical experts have expressed concern at China's crackdown on ketamine. While the drug is sometimes abused, it is also a very important and safe anaesthetic, and any restriction would be a major blow for safe surgery in poor countries, they say.

My weekly medical news blog for 7th February

There have been few takers for GP training places in Nanjing. The city's community health centres need to recruit 110 family doctors to fill their positions but have only had 49 applicants. Under new health ministry regulations, all doctors including GPs must have the 5+3 education and training (5 years undergraduate and 3 years postgraduate.) However, despite offering a masters degree and a one month placement with GPs in Taiwan, most medical graduates have given the GP training scheme the cold shoulder. The reason is the low status and poor pay of 'community doctors'. After eight years training, GPs can expect to earn only about 80,000 yuan (US$13,000) a year, which is much lower than hospital-based specialists earn. Also there is no chance of promotion or career progression and GPs are expected to move around many clinics in suburbs and villages. Health educators say the Chinese government needs to put more emphasis and resources into primary care if it is to develop a healthcare gatekeeper system similar to those used successfully in developed countries.

Most of the 'research' published by China's doctors is rubbish and there's a simple reason for this - the publish-for-promotion system. To gain promotion (and often just to stay in the job) all China's doctors have to meet a certain quota of  papers published in medical journals. The problem is that most of China's doctors are way too busy treating patients to be doing research and writing up papers. Many are simply not interested. The result is a thriving industry in academic fakery and plagiarism. It is common knowledge that doctors hire 'publishing agents' and ghostwriters to source the articles that will be published under their name. Ironically, many of the articles are written by medical students, and so there is an inverted system whereby the most knowledgeable and experienced clinicians are publishing articles written by the least knowledgeable. The going rate is about 3000-4000 yuan for a good paper - payment on publication, of course. Experts say the system has become a wasteful farce, and they are calling for reform of the one-size-fits-all quote system, to divide doctors into three categories: 'craftsmen' (no research, just treating patients), physicians (some research) and medical scientists (more  research, fewer patients).

The government says it expects to see a dramatic increase in uptake of private medical insurance before 2020, with new policies encouraging Chinese citizens to take out private cover. Ma Xiaowei, deputy head of the health ministry, the National Health and Family Planning Committee, told a news conference this week that the central and provincial government would "encourage the development of various types of commercial insurance to increase people's ability to deal with risks posed by major diseases." He said private cover was needed to help fund demand for health services, with the number of people over 60 already exceeding 200 million. However Mr Ma didn't explain how people will be enticed to take out private health insurance given that there are currently virtually no private doctors or hospitals and very few services or benefits from having insurance.

Underpaid, overworked and under fire: that's the life of an emergency medicine specialist in Guizhou province, according to a Sina article this week. In China, emergency doctors accompany ambulances and are often first on the scene of trouble, even before police. One doctor said he often had to jump in and stop bleeding in stabbing victims while people were still fighting around him. Another said emergcny doctors were often faced with physical challenges such as getting critically ill patients down stairs of apartment blocks with no lifts. Emergency doctors said they worked 24 hour shifts then had a day off during which they mostly slept, and there was no time for leisure, holidays or study. The stress of daily life as an emergency doctor meant there were high rates of burnout - and doctors were considered grizzled veterans if they lasted three years, they said.

In clinical news, new research shows that older Chinese are consuming more calories - and eating more unhealthy food - than their counterparts of the previous generation. A study from nine provinces found that the average daily energy intake had increased among older Chinese adults from 1379 total kilocalories in 1991 to 1463 kilocalories in 2009. The increases had come from greater consumption of high fat and high carbohydrate foods such as plant oil, wheat buns, and wheat noodles.

Chinese are also consuming more polluted air and it is killing them as much as smoking. A study carried out by the School of Public Health in Peking University found that there were
257,000 premature deaths related to PM2.5 pollution in 31 major Chinese cities. This made air pollution a major killer equivalent to smoking. Conditions such as lung cancer and stroke triggered by air pollution killed about 18,000 people in Beijing alone in 2013, the researchers said.

And finally, a study from Shanghai as shown that the number of cervical cancer diagnoses in the city has increased six fold in the last decade. Data from 13,518 women with gynaecological cancers  from 2003 to 2013 showed that the number of women with diagnosed gynaecological cancers increased by almost sixfold with the increase largely due to the increase of women with newly diagnosed cervical cancer. The study also showed that the age of diagnosis of cervical cancer had increased.

Chinese prefer foreign brands - especially when it comes to medical journals

One of the more provocative articles in the China-themed Lancet this week is a brief letter from two orthopaedic surgeons in Xian. 

Dr Yang Junsong and Dr Hao Dingjun complain about the quality of medical journals in China and how Chinese clinicians invariably prefer to be published in foreign medical journals. This is because of the publish-for-promotion phenomenon which I touched on last week - to gain promotion in a Chinese hospital, a doctor needs to acquire a list of published research, and the greater the Impact Factor of the journal the better.

As Drs Yang and Hao remark, there has been a tidal wave of medical journal articles published by Chinese clinicians in recent years, and yet medical publishing is in crisis. Why? Because most of it is crap. Scholarly articles are not being published to to be read or to further scientific knowledge, but to be listed and to obtain the magic piece of paper that counts towards career advancement.

Well, you might say, this sort of things happens to all academics and clinicians  and you'd be right. But the scale of the problem in China - and the sheer numbers involved - means this is distorting medical publishing and also drowning out the genuine research and academic discussion that deserves to be published but which struggles to reach the most suitable audience.

Another problem noted by the doctors from the Medical College of Xi'an Jiaotong University is that most doctors in China don't read English language journals. They may only have access to Chinese language journals and these are poor in quality because they being neglected by Chinese researchers - and they are also often profit seeking rather than having any sense of collegiality. As the authors note, Chinese doctors deal with 4 billion patient consults a year and they depend on Chinese medical journals as their main source of medical information - if this is rubbish, where can they get good quality research,  evidence and discussion from to inform their practice?

"Rebuilding a scientific and reasonable assessment system for medical research would be an essential step for the Chinese government," the authors conclude.

This isn't the first complaint about medical publishing in China. The Economist touched on the  problem of poor quality - and sometimes fake - medical research publications last year. Other bloggers have also highlighted the bizarre practice of bonuses paid to researchers in China in proportion to the impact factor of journals they get published in: $300 for a low impact journal, and the jackpot of $30,000 for getting a paper in Science or Nature! This reminds me of Chiang Kai Shek's system or rewarding his air force pilots with dollar bonuses for every enemy aeroplane they shot down.

I can only agree with this article by a frustrated academic: "We must stop the avalanche of low quality research..."

The Lancet devotes an issue to China

The Lancet this week has China has its theme, and includes many interesting articles on a wide range of topics around medicine and health in China. 

There's a huge amount of material there and I don't really know where to start in reporting it all. The articles cover everything from China's medical education system, the challenge of non-communicable diseases and even a couple of clinical research articles on pulse oximetry for screening newborns for cardiac disease. For me, the most interesting article is one on the recent change of course in China's health reforms to put emphasis on private hospitals. The authors of the review, from Oxford and Harvard universities, say this move is a retrograde and negative step that will run counter to many of the other recent reforms that aim to encourage equity and more efficiency in China's user-pays hospital based system.

The Lancet also includes several articles on the theme of preventing chronic diseases such as obesity - a very timely issue as China becomes more wealthy and starts to see the same lifestyle diseases such as diabetes that are already so common in more developed countries.

For me the other interesting section in this China-themed Lancet is the letters page. There are several letters from doctors in China commending the journal for highlighting the problem of violence against medical staff in China - and all put the blame on the underfunded health system and overworked doctors. On a related theme, doctors in China also lament the drop-off in applications for medical school - few young Chinese want to become doctors these days, as it is seen as a difficult and dangerous job that requires many years of study for little reward.

And any coverage of the medical situation China would not be complete without comment on the difficult status of organ transplantation. Quite a few doctors take issue with a recent Lancet article claiming that 'a new era' in organ donation is about to begin. They point out that China has about 200,000 require an organ transplant but there are only about 2000 donors. Read the full article to find out why.

My only criticism of the Lancet China issue is the too-deferential interview with China's health minister Li Bin, who gets to trot out all the claims of progress with reforms, without really being challenged about the many problems and contradictions with them. Oh, and the omission of any coverage of primary care [or lack thereof] in China ...

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.

Academic fraud doctors swindled out of 5600 yuan by ghostwriters

by Michael Woodhead
Two doctors from Suzhou who tried to publish fake articles in medical journals found themselves to be the subject of fraud when their 'ghostwriters' pocketed 5600 yuan. 
The two doctors attempted to cheat on medical publishing requirements for promotion by getting an online 'writing agency' to write an article in their names and have it published in the "China Medicine" journal. The deception arose because in China it is necessary for doctors to get work published in journals in order to obtain advancement in their careers. The two Suzhou doctors felt they didn't have the time or the inspiration to do an article of their own, so they turned to an internet ghostwriting agency website that offered writing services for such situations. The website promised that an article could be written on a topic of their choice and published in the "China Medicine" journal. The doctors paid  2800 yuan and sent a list of suggestions for the article content.
At first the writing agency seemed very competent, and sent them a manuscript for their comments and revisions. The agency then asked them for a further 2800 yuan for publication fees. However, when the doctors sent the money, they never heard anything more from the online agency. When they checked the website of the China Medicine journal they found their article had not been published. They later found that the agency had a fake address and the phone had been disconnected. The  doctors reported the fraud to the police, but they were unable to track down the fraudsters. The police advised anyone thinking of publishing to check the publisher credentials.

Medical publisher to expand in China

The medical journal publisher Elsevier announced today that it is strengthening and refocusing the scope of its long-standing relationship with China Science Publishing & Media Ltd. (CSPM) to create an international publishing platform for English-language medical journals that brings the expanding wealth of research originating from China to the world.
The announcement from Reed-Elsevier, which publishes medical journals such as The Lancet, comes at a time when China is emerging as a major contributor to the international scientific community, being the second most prolific publisher of research articles after the US and ahead of the United Kingdom.