Why is there so much violence against doctors in China?

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

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

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

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

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

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

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

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

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

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

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

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

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

Medical school places unfilled: nobody in China wants to be a doctor, and there are three good reasons why they don't

In western countries there is fierce competition to get a place in medical school. Only straight A students with an impressive portfolio of extra-curricular activities need apply. In China, the picture is very different. Even the top medical schools in China are struggling to attract students.

This week, Professor Yang Jun a distinguished cardiologist and head of the First College of Clinical Medical Sciences, Hubei, notes that Shanghai's prestigious Fudan University has had to drop its entrance mark threshold by 58 marks this year. The same "dumbing down" has been seen at the city's Jiatong University medical school and other medical schools across the country. When China's top medical school at  Peking Union Medical College allotted 10 places to Guangzhou students, only four applications were received - and of these only one was deemed to make the grade.

What's happening? The fact is, nobody with any ambition wants to be a doctor in China right now, and you can see why. The three main reasons are poor pay, long hours and terrible working conditions - including the real possibility of abuse and violence.

Writing in the International Journal of Cardiology, Professor Yang notes that the average salary of a doctor in China is 72,000 yuan a year (US$11,600) -  and many doctors earn a lot less than that, especially if they work in unpopular specialities such as paediatrics or emergency medicine (the so-called ambulance riders).

Poor pay for doctors in China: paediatricians are at the bottom, with only 63,000 yuan a year

For this salary, doctors have to work long hours - more than 50% of doctors work more than the 'specified' 40 hours a week and 30% work more than 60 hours a week.  Doctors also face huge workloads - as many as 80 patients in a single morning shift. As Professor Yang observes, the Mayo Clinic in the US has fifteen times more staff than the Peking Union Medical College, and yet it has only half the patient numbers.

Doctors in China simply don't have time to practice adequate medicine - and the consequences are unhappy patients who take out their frustration on staff. A recent survey of almost 10,000 doctors found that 60% had recently experienced abuse from patients, and 13% had experienced physical assaults.

Doctors also have to study long and hard to qualify - up to ten years including undergraduate and postgraduate qualifications. On top of this they have to publish articles and to gain academic merit for promotion.  Doctors have lost the status and respect they once had - and only 6.8% of doctors say they would advise their children to follow  a career in medicine.

This is already causing problems in the less popular branches of the profession. On 27 July, the National Health and Family Planning Commission announced that it would be waiving the usual entry criteria for admission to the specialities of paediatrics and emergency medicine. Medical student candidates who did not achieve the usual pass mark would be allowed to become trainee paediatricians and emergency medicine doctors if their coursework was of sufficiently high standard, the NHFPC announced. This has caused outrage among  doctors currently working in these specialities, who say it is a desperate and self -defeating move that will further reduce the attractiveness of their branches of medicine.

They say there is a need to improve pay and conditions in their work rather than lowering the bar to entry. Paediatrics and emergency medicine and notoriously poorly remunerated and yet high pressure jobs in the Chinese healthcare system. Assaults on doctors in these departments are numerous as they are in the front line seeing critically ill patients - especially the treasured offspring in a one-child system.

The doctor's social network site DXY echoed many of the criticisms of the "dumbing down" move. As one doctor wrote: "We work longer hours for less pay in unsafe conditions, but we stick to our posts because of the duty we have to the little ones who thank us after we have care for them."

What are hospitals like in China? (Answer: congested)

by MICHAEL WOODHEAD
Another week and another series of brutal attacks on hospital staff in China. This week it was the turn of an unfortunate female neurologist in Huizhou, Guangdong, who had her hand almost severed when she hacked with a machete by a disgruntled male patient. The man said he was unhappy with his treatment and attacked without warning when the doctor was on her ward rounds.

The authorities have made the usual responses - they have arrested the offender and tightened up security at the hospital. Tributes and donations have poured in from citizens sympathetic to the plight of the injured doctor. A petition against violence in healthcare has garnered half a million signatures from doctors - and the Guangdong health department has ordered that all medical institutions have a police office installed and manned around the clock.

The attack was one of 12 high profile violent incidents against health staff that occurred last week in China - including the smashing up of the 301 PLA Hospital in Beijing. What is the underlying reason for these attacks? One of the main factors often mentioned is that China's hospitals are simply overloaded and cannot offer adequate care to all patients - who then become angry and violent.

Is this because China's health system is underfunded or inefficient? Some interesting answers on the real situation about China's congested hospitals emerged this week in a lengthy paper in the academic journal Health Policy and Planning. It's worth reading if you want to know the background to China hospital system and how it got into the mess it's now in.

The authors paint a much more nuanced picture of China's hospital system than the usual overcrowded/underfunded/profit-seeking complaints. First of all they bust some myths. For a start, China's healthcare system is not massively underfunded by international standards - but it is  unevenly funded, with most resources devoted to city hospitals.

Also, China's hospital system is not uniformly overloaded - only the tertiary (highest level) hospitals are. The lower-level hospitals at county and township level are often underused and deserted because patients flock to what they perceive as the top quality care available at tertiary hospitals in cities.

The authors explain that this has come about for two reasons. Firstly, when China's hospitals were reformed by Deng Xiaoping, the high level city hospitals got a lot more investment and incentives than the township and country hospitals. This created a vicious circle because the large hospitals were able to invest in better equipment, and attract more patients. better staff and thus earned more 'business' (and income) while the county hospitals lost out.

However, the high level hospitals had two problems - they invested in infrastructure rather than staff, creating a shortage and misallocation of skills at the tertiary hospitals, where many staff are wasted dealing with minor illness.

Secondly, the tertiary hospital were bound by tight regulations on prices for essential drugs and medical services.  To overcome this, they invested in many unofficial services (eg cosmetic surgery, fertility clinics etc), which diverted resources away from frontline care. The restrictions on prices meant that hospitals had to overservice to gain more revenue - but it also meant that patients had no 'price signal' to seek care from local hospitals. They could get good care  at the tertiary hospital for the same price - even if it meant facing overcrowding and rushed consultations.

This, then, is the current situation in China's hospitals - an imbalanced system in which all patients flock to the short-staffed higher level hospitals, creating congestion and strife. The article by Dr Sun Zesheng and colleagues at the Zhejiang University of Science and Technology, Hangzhou, offers a simple solution: deregulate prices. They say that tertiary hospitals should charge a premium for their services, and patients should be encouraged to seek less expensive alternatives for non-urgent care at local hospitals and clinics. However, they also warn that the government must invest in better equipment and medical staff resources at lower level hospitals.

Until that happens, the big city hospitals will remain congested - and the pressure (and attacks) on staff will persist.

China healthcare headlines - June 2015

Beijing to ban smoking in public place 

Smoking will be banned in public areas of Beijing such as restaurants, offices and on public transport from 1 June, but enforcement is in doubt. According to the new anti-smoking rules, smokers will face
fines of 200 yuan ($32.25) for smoking near hospitals and schools, while business can be fined up to 10,000 yuan ($1,600) for failing to enforce no-smoking areas.

Doctor killer executed

The man who stabbed a doctor to death at a Wenling hospital in a dispute over  surgery outcomes has been executed in Zhejiang. The man called Lian Enqing murdered an ENT specialist in October 2014 because he was upset about the poor results of surgery on his nose.

Air pollution triggers hospital admissions

Hospital admissions for respiratory problems increase dramatically when air pollution PM2.5 particle levels exceed a threshold of 200 µg/m³ according to researchers from Shandong.

Lian Enqing was sentenced to death last year for a fatal attack on an an ear, nose and throat specialist in Wenling, in the eastern province of Zhejiang. He attacked the doctor because he "felt displeased with his nose and claimed to be suffering respiratory problems", the official news agency Xinhua said - See more at: http://www.straitstimes.com/news/asia/east-asia/story/china-executes-patient-who-stabbed-doctor-death-over-nose-operation-report#sthash.mIPzSQ7W.dpuf

Lian Enqing was sentenced to death last year for a fatal attack on an an ear, nose and throat specialist in Wenling, in the eastern province of Zhejiang. He attacked the doctor because he "felt displeased with his nose and claimed to be suffering respiratory problems", the official news agency Xinhua said - See more at: http://www.straitstimes.com/news/asia/east-asia/story/china-executes-patient-who-stabbed-doctor-death-over-nose-operation-report#sthash.mIPzSQ7W.dpuf

Private hospitals blocked by public hospital chief

Despite being encouraged by central, the development of private hospitals is being blocked by the all powerful managers of major public hospitals, according to an article in Caixin. Analysts say that public hospitals are effectively operating as for-profit monopoly providers and they are loathe to give up their staff or patients to private newcomers.

Health minister's book published by Elsevier

Former health minister Chen Zhu is having a book publichsed by international medical publisher Elsevier. The book entitled Healthy China 2020: Strategic Research Report, is an in-depth review of China's past present and futre healthcare developments, with contributions frm many leading healthcare figures.

China's hospital league tables published

A league table of China's best hospitals, ranked by department, has been published by the China National Medical Information Center. The ranking tables put hospitals in the three major cities of Beijing, Shanghai and Guangzhou at the top of most lists, according to criteria for 19 different specialities.

Drug sale reforms; Autistic children abused; Tibetan monks don't get hypertension; Guangzhou's first private clinic; Doctors stabbed in Fuzhou; Tax breaks for private health insurance

by MICHAEL WOODHEAD
The move to stop county-level hospitals from deriving their income from 15% markups on pharmaceuticals will severely dent their revenue stream and threaten services, health economists have warned. China has already trialled  drug commission bans in 300 county hospitals and now plans to extend the system to 1000 hospitals nationally, Caixin reports. However, the plan could leave hospitals short of funds and thus reduce the level of services and hurt the morale of medical workers,  academics and doctors say. The State Council has said local governments should help hospitals to make up for the lost income from drug sales. However,Wang Zhen, a research fellow at the Chinese Academy of Social Sciences, said local governments were already strained financially and they don't have extra money for hospitals.Wang said that without government subsidies and other measures in place, scrapping the markup practice might wind up creating other problems because hospitals will find alternative ways to make money.

Children with autism in China face experience high rates of physical abuse from their parents and family members, a study from Henan shows. In a survey of 180 children with autism, Zhengzhou researchers found that 36% had recently experienced severe physical maltreatment such as slapping on the face, being beaten with objects or kicked. Less severe physical maltreatment such as being slapped, or shaken was experienced by 86% of autistic children.

Tibetan monks have low rates of hypertension, according to a study carried out in Gansu. The survey of 984 monks found that 19% had hypertension, compared to 34% of the local population. However, despite having low rates of high blood pressure, there were also low rates of awareness, treatment and control of hypertension among monks, the researchers found.

Encouraged by new government policy a surgical oncologist has opened Guangzhou's first major private clinic. The clinic set up by Dr Lin Feng will offer speedy diagnosis and high quality treatment by a well known surgeon previously practicing at the renowned 3rd Hospital of Guangzhou. The clinic charges about 2-3000 yuan fees, and offers high quality diagnosis and surgery without the long waits and rushed consultations of public hospitals, its operators say.

Two doctors at a Fuzhou hospital were stabbed in an attack by a 66-year old male patient, local media report. One male and one female doctor were seriously injured by the man armed with a 40cm knife who had been attending the Fuzhou hospital to have his haemorrhoids treated. A hospital spokesman said the man was unhappy with the treatment he received for his haemorrhoids and stabbed a female doctor in the hip. The male doctor who tried to restrain him was also stabbed in the arm.

Tax breaks are to be introduced for Chinese consumers who take out private health insurance, the government has announced. People who spend more than 2,400 yuan on commercial health insurance policies per year will now only pay individual taxes on income above 3,700 yuan per month, instead of 3,500 yuan, CCTV has reported. The move is part of a government campaign to encourage Chinese people to  purchase private health policies in addition to their standard government benefits.

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.

My weekly news blog for 1 Feb

The medical news in China has been dominated this week by the death of a doctor at a Luoyang hospital after a brawl with a drunken patient. Both fell down a lift shaft and were killed. It's just the latest in a long line of violent incidents against medical staff. Each time one occurs there are protest by staff, stern editorials in the media and vows to crack down on such incidents. There have even been gimmicks, including plans to have 'volunteers' or police patrols in hospitals to defend doctors from violence and defuse violent situations And yet still they continue. I can't understand why Chinese hospital don't have 'crash' alarms like they do in western countries, that trigger lockdowns and mutual protection protocols.

On a more positive note, Chinese drug makers have registered the world's first Sabin-inactivated poliovirus vaccine (S-IPV). The vaccine, developed by the Chinese Academy of Medical Sciences is being produced by the Institute of Medical Biology within the Kunming Hi-Tech Zone. It is said to be more effective than the current oral polio vaccine and also inexpensive.

Such a vaccine may have a role in remote parts of China such as Xinjiang, which recently reported an outbreak of polio. After more than a decade being polio free, in 2011 there were 23 polio cases reported, 55% of which were in young adults.  The polio was presumably brought in from the neighbouring Muslim state of Pakistan, where polio has not been eradicated due to the Taliban.

Another first for China this week was the first patient to be treated - and survived - a new H5N6 strain of avian influenza. The patient treated by well-known specialist Dr Zhong Nanshan at Guangzhou hospital after contracting the infection from - guess where - a live poultry market (why don't they just shut them down for good?). Dr Zhong said this was the second patient to contract the dangerous infection - the first one died. he said the second patient had been treated with high doses of antivirals and was in a stable condition. China is also struggling with a winter outbreak of H7N9 avian flu, with 30 cases so far around Guangdong.

In the healthcare reforms, some healthcare managers have said that hospital reforms should focus on the model of funding, and switch to an 'activity based funding' system to reward outcomes. At a meeting of the Beijing Chinese Peoples Consultative Committee they said that the funding system based on "diagnosis-related groups" (DRG)  would "break the link between doctors' incomes and prescriptions, thereby preventing excessive medical treatments and over-prescription of drugs." Hospital managers complained that they were underfunded because fees had been fixed at low prices set in 1999 whereas costs (and incomes) had risen considerably since then.

Well, fees may be too low according to hospital managers, but some patients still can't afford them. A woman has made news in Kunming by dressing up in a wedding gown and offering herself for marriage to any man who will pay her brother's medical fees. Her brother has leukaemia and she says he needs 300,000 yuan for treatment. China is supposed to have a public health fund for people with catastrophic illness, but it obviously hasn't trickled don to this young man.

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.

Daily Mail fake miscarriage | 120 seconds per patient | Dogs a hepatitis risk | Atrial fibrillation untreated

The Daily Mail has been running a fake story claiming that a pregnant Changsha nurse had 'lost her baby' after being attacked by relatives of a cancer patient who died. Chinese media reported the attack but said she was fortunate to have avoided a miscarriage.

A doctor at a Guangzhou hospital could only spend an average of one and a half minutes per patient when he was the only clinician on duty and had a waiting room of 100 patients to see in one morning.

About 20% of dogs and 6% of cats in Guangzhou are infected with hepatitis E, a new study has shown. The high rates of hepatitis infection should raise concern about the eating of dogs, warn researchers from the South China Agricultural University.

China should not copy the US private model of healthcare according to Nobel prize winning economist Daniel McFadden, of the University of Southern California. Professor McFadden said that when looking at healthcare systems around the world, the most efficient are those where the community medical providers are either employed by the government or employed by companies that are largely contracting to the government and not operating as private businesses.

Hospital staff in the Muslim Xinjiang province have been told not to fast during Ramadan. The request was made at a meeting on upholding ethnic minority unity, “in order not to affect normal work and life." Muslim hospital staff members were requested to sign their pledge of compliance in a “responsibility book.”

One in ten emergency department patients leave without being seen by a doctor, according to a study carried out in Chengdu hospitals. Those who left tended to be families who arrived on foot with children who had less serious problems.

Most Chinese people with atrial fibrillation go untreated, with only 40% receiving anticoagulants, according to a study from Fuwai Hospital and Peking Union Medical College, Beijing.The study also showed that only 26% of people treated for  atrial fibrillation received adequate treatment.

Reform of the medical school curriculum is needed in China as many medical schools are still using outdated and ineffective teaching methods that fail to keep pace with developments in medicine, according to a study from Tongji University, Shanghai.

Iron deficiency anaemia is common in rural parts of central China, where only about 40% of infants have an adequate diet, a study by the UNICEF Office for China, Beijing, shows. Malnutrition and anaemia was more of a risk for ethnic minorities and for those living in poor mountainous areas.

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.

Private health is the centrepiece of health reforms in China

A few news items from this week:

Medical tourism project for Hainan

Hainan province is building what it claims to  China's first special zone for medical travel, to try attract elderly people in search of  a cheap and clean place to spend their retirement.
The Boao Lecheng International Medical Travel Zone covers an area of about 20 square km and the provincial government will create preferential policies to attract overseas medical institutions including lower taxes for imported medical instruments and medicines. Medical tourism has been backed by China's health minister, Li Bin, who said  it "will make Chinese medical institutions take steps to adapt to international demand, so that the overall standard of medical service will be enhanced."

Private hospitals given preferential treatment

To encourage private hospitals, the government is to allow them to charge whatever prices they want and also force health insurance providers to cover treatment in private as well as public hospitals. New measures announced by the National Health and Family Planning Commission include relaxing price controls covering non-public hospital services. The decree also states that all private hospitals should be included in the country's public medical insurance schemes - so long as they reach the basic  standard for 'designated' hospitals -  and government departments should implement the same reimbursement policy for both public and private hospitals. Privately-owned hospitals have welcomed the measures, especially the decision to treat all hospitals equally regarding the reimbursement of patients' medical costs.

Foreign private doctors shown favourably on TV

Chinese TV is giving positive publicity to the handful of foreign doctors working in private clinics in China. In a programme this week CNTV says foreign doctors are "flowing" into China and helping to meet the needs of China's healthcare industry.
"Alongside providing advanced treatment for patients who can afford it ... they can contribute with their knowledge and experience, in Chinese hospitals." the programme stated.

Another doctor killed by patient

A doctor has been killed in Jiangsu reportedly by a 45-year-old male patient who was angry about the outcome of a circumcision procedure. Dr Shan Erhui was stabbed to death in the lounge of a hospital in Fengxian county on Tuesday. The suspect, Wang Fangli,  underwent circumcision in the hospital on March 30 and had antibiotic treatment afterwards, and was said to be dissatisfied with the treatment outcome and the medical expenses.

Volunteers sought to protect doctors from violence

Beijing hopes to recruit 1500 "Guardian Angel" volunteers to act as intermediaries between doctors and patients, defusing disagreements and smoothing over tensions, according to Xinhua. The plan seeks to use students and patients who will serve a one-year 'guardian' term in 21 hospitals in the capital.
“Patients will understand doctors better after talking with our volunteers,” said Feng Guosheng, head of the Beijing Municipal Administration of Hospital.

3 trillion yuan invested and doctors still underpaid

The financial journal Caixin has a feature on how doctors in China still have low incomes despite the 3 trillion invested in the health system by the government. The article says that unless reforms are introduced, medical workers will continue to be paid a pittance -  especially in small town and rural hospitals. It quotes a health ministry spokesman as saying that medical reforms will fail if the "key issue" of doctors' incomes is not solved. The government says it needs to fix the problem of low pay and doctors incomes being linked to prescribing of drugs. It aims to do this by allowing doctors to work in private clinics and to charge higher fees.

Public not happy with expensive private clinics

The Chinese government may see private clinics as the way of the future, but few ordinary citizens in Shanghai can afford their fees. There has been strong criticism of a new private hospital in Shanghai that charges patients up to 1,200 yuan to see a doctor, when it costs just 50 yuan to see a doctor in a public hospital. The opening of Shanghai International Medical Center (SIMC) is being criticised as a symbol of the move to cater only to the well-off in a society.

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.

Dr Zhong Nanshan: what's wrong with China's health system and why we need to get doctors on board to fix it

by Michael Woodhead
Dr Zhong Nanshan is one of China's most well known and respected doctors. A respiratory physician and former head of the Chinese Medical Association, he is the 'hero' of the 2003 SARS infection outbreak, and his frank advice is respected by the government. At this week's meeting of the National People's Congress in Beijing, Dr Zhong gave a speech on the current problems with the Chinese healthcare system and the direction of health reforms.

"Today when I heard Premier Li Keqiang's announcement I was very excited, as his words provided a lot of inspiration on the difficult problems we are facing with medical reform. In recent years China's reforms of health insurance and the healthcare system have attracted worldwide attention. But from the public's point of view, there is still the problem of 'difficult to see a doctor, expensive to see a doctor'. Doctor-patient relations are still tense (as the China Hospital Association has recently made clear, hospital doctors and staff have often been the victims of violent  attacks) and hospital staff are not showing enthusiasm or initiative in their work.

For these three criteria, when it comes to health reforms there has been no breakthrough in the last five years, and in fact things have become worse in some areas. Where does the blame lie? The answer is in our major (tertiary level) hospitals.  In these institutions, doctors have not become heavily involved in medical reforms, and this problem is becoming more serious. Look at land reform: this was about the relationship between farmers and landlords, and it was based on respecting the position of the farmer, allowing them to make a living. Likewise with education reform - this was about teacher-student relations and when teachers and schools got better pay, resources and conditions, teachers got more respect.

Why are doctors not enthusiastic for health reform?

Similarly, medical reform will depend on the involvement of doctors. America's medical reforms were about respecting medical opinion and allowing the doctor's clinical judgement to drive the direction of the medical system. I remember in 2012 when Li Keqiang was deputy premier and I saw him at a meeting, and I told him that the most important point I wanted to make was that doctors must be the driving force behind medical reform. However, five years have gone by and it seems that under the present reform system medical staff can see no way in which they can change things for the better. On the contrary it seems that many of the reform programs have an adverse affect on the working conditions for doctors. For doctors it is as if society 'discriminates against them'. And under such conditions, where is the enthusiasm for medical reform going to come from?

As any changes are going to affect doctors' interests, let us first analyse the current situation in regard to doctors' incomes. It is a widely held belief among the public and some government departments that doctors' earn a large amount of extra and unjustified income through what we could call unofficial 'grey channels', and this is seen as outrageous, unethical behaviour. Therefore, before the conference I examined the accounts of the Guangzhou tertiary hospitals. These showed that in 2012 the average official annual salary of a doctor was 41,077 yuan, but the actual annual income for a doctor with all allowances, bonuses and subsidies was 176,320 yuan. For 2013, the average official salary for a doctor was 46023 yuan, but their actual annnual income was more than 190,000 yuan.

Of course this level of income is high compared to the average worker or government official, but it is low compared to the incomes of doctors in other countries. It may therefore be said that this level of income for doctors is reasonable, especially when this extra income comes from government policies as they are applied in hospitals. Here is a typical example of how state-owned enterprises operate to improve performance: hospitals want to increase their income so they increase the number of beds to accept more patients and they increase the number of procedures and tests. On my ward rounds I see many patients who are having unnecessary tests and procedures. One of the main reasons for this is that doctor's income is linked to irrational medical practices - this is a major contradiction within our health system.

Reward doctors for their skills, not for how much they prescribe

My second major point is that a doctor's economic labour value is not reflected in medical fees in China, which are far too low. A doctor's economic value should be related to their ability to diagnose and treat and their ability to give individual attention to a patient based on their skill and knowledge. Unfortunately, in China this is not the case. In the rest of the world a doctor's income depends on their clinical skills, whereas in China a doctor's income is linked to how many drugs they prescribe and how many tests and treatments they order. It is not surprising then, that in China doctors' credibility is called into question. But rather than blame this on a doctor's ethical flaws, we should recognise that this is due to hospital policies that prioritise income and profit and skew the doctor's working patterns.

Too many patients, not enough time

My third point is related to the tense situation in doctor-patient relations. I believe this is 80% due to the difficulty that patients have in accessing a doctor. Owing to the way hospitals operate, doctors are given quotas of numbers of patients to be seen each day. If they do not meet the targets for numbers of patients treated, they miss out on their financial bonus. In other words, the more patients they see, the better. Thinks about this: in half a day a single doctor must see fifty or sixty patients. What does this say about patient access to a doctor and the doctor's 'space' to practice good medicine? The reality for patients is "wait for three hours to see a doctor for three minutes". That just isn't enough time for a proper consultation, and as the consultation time shrinks, the strained relations between doctors and patients increase.

These days in a bid to exploit 'resources' to the full, hospitals are always seeking to increase their bed numbers and they open 'branch hospitals' to increase capacity. While in theory this increases the opportunities for the population to get treatment, the reality is that this increases the hospital income. And the other aspect is that doctors are 'running to exhaustion' trying to treat ever higher numbers of patients. This is not a sustainable model for providing for a community's medical needs.

So we have doctors who see that the government health system cannot provide them with a basic income in proportion to their work and skills. They thus see no benefit from medical reforms so far: they have a negative view, show little enthusiasm and no initiative towards medical reforms. Therefore, as the public should be the target for healthcare reforms, I could set the theme of my speech today as: "Discard doctors as driver of health reform: don't let the medics change the medical reform."

Principles: the need to put more value on health

The way to solve these problems is to change our principles. Today I especially appreciated hearing Premier Li Keqiang's remarks that: "For existing problems the government should look within itself for the causes." I think for health reform we need to look within the health system for the causes of the problems.

Firstly, within both government and society we need to develop a respect for life, to treasure life and health. And if we are to attach importance to preserving life and health we must invest in the health system. From 2005 to 2012 our country made great efforts in health and increased funding for health from 3% to 5% of GDP. However, this is still a lower level of health funding compared to developed countries - in fact we spend less on health by GDP than Afghanistan does. Developed countries spend between 8% to 15% of GDP on health, and we need to aim for that.

But we can't just think of health in economic terms. Health reform must start by putting health and life as a first priority for society. At present in Chinese hospitals the economic value of the healthcare staff is very low compared to other countries. The incomes  of public hospital medical staff are very low and should be higher. Other countries have managed to create good public hospitals systems, why can't we?

Use public insurance funds to improve health services

Of course China has a huge population, and we can't expect our public hospitals to immediately become public welfare providers for everyone. We have to look to the health insurance system for the potential to do that. Since 2011, the national health insurance scheme has been meant to guarantee access to medical treatment and medicines. However the system is fractured and un-coordinated, and those benefits have not been realised. Since 2009, the rural medical insurance scheme has shown good results but these have not been seen with urban insurance schemes, which still have major problems.

Health departments lack the management skills to oversee these schemes, and although the public have paid a lot into these public insurance schemes, the benefits have not been taken out. We should look to these accumulated health funds as resources to fund health reforms. We need to focus on the supply side, not just on patient input and demand. If doctors show good performance they should be rewarded for providing more services. Hospitals should be able to use this insurance funding as a lever to deliver more and better services - but currently the health insurance funds are out of their control and managed by the social welfare department.

The social welfare department does not accept responsibility for health reform and this is a major obstacle to reform of public hospitals and the way that funding is raised, dispersed and linked to performance of the public hospital system. In 2010 there was something like a 7 billion yuan surplus in health insurance contributions - why is this surplus not being used to boost the public hospital provision of services? The health department does not have funding for hospitals - this system needs to be changed - as in 70% of foreign countries where health departments manage public hospitals.

Hospitals should be centres of excellence

Finally we need to improve the education and culture of healthcare staff. We need to have a system based on merit. In most countries, large hospitals are centres for medical expertise and do not deal so much with common, everyday problems. These are dealt with by family doctors or community clinics. Last year the government's health working group made the creation of community clinics and hospitals a priority. I strongly approve of this. Through investment the government should improve the skills and the remuneration and conditions for community clinics and local hospitals. I think the technical and management skills of small hospitals and clinics should be nurtured and overseen by tertiary hospitals, which take responsibility for community clinics. In this way the standard of local clinics could be increased to allow them to cover the same scope of basic care as tertiary hospitals within 3-5 years.

In summary, across the world, the medical profession is regarded with respect in most countries, but China is the exception. The economic value of medical personnel has been degraded, and until this is restored they will not be at the front of driving health reform. The medical staff of Guangzhou University Hospital have great underlying enthusiasm for health reform - it just needs to be shown that reforms will bring them benefits and respect, for them to be positive and actively support them, I believe. I think that in this respect Guangdong doctors will be at the forefront of reforms. We will work together to fulfill what Li Keqiang described as "a solution with Chinese characteristics to the difficult problem of health reform."

Editor's note: This is my translation of Dr Zhong Nanshan's speech that was made at the NPC meeting in Beijing on 5th March, 2014 and published in the People's Daily. It is not a perfect translation, but I have covered the main points as best I can. If you see any errors I will be happy to correct them. The original can be seen in Chinese here.

Nanjing Hospital nurse and doctor injured in attack by top official

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

Today's medical news: an idiot and 'special care' patients

by Michael Woodhead
"Medical staff are incompetent and deserve to be cut with a knife" - that's the opinion of TV personality Wang Mudi who is described as a Guangdong TV finance news presenter and producer. He made the remarks on Weibo after  he took his girlfriend to a hospital to have treatment for a skin allergy. Mr Wang took his "Little Bunny" to have an IV  'infusion' (the Chinese cure for everything - oral drugs are seen as inferior) for the rash on her hands. Unfortunately, the nurse at the hospital took four attempts to find a suitable vein for the IV line, causing the girlfriend much pain and distress. Wang complained online to his 370,000 followers about the nurse's insolent attitude and said he would like to chop someone with a knife. His remarks drew a lot of negative feedback online in light of recent attacks on medical staff - including he killing this month of an ENT surgeon in Heilonjiang. Wang later apologised on Weibo and tried to justify his remarks by saying the nurse had been chatting away to someone else and didn't seem to care - and didn't apologise either. However, doctors and nurses said Wang's remarks encouraged attacks on medical staff and he wasn't fit to be on TV.

From 'red envelopes'  to 'special needs'
Following on from my post about red envelopes and the culture of bribery and connections in Chinese medicine yesterday, the business magazine Caixin has a timely feature on China's "special care patients" - a euphemism for super rich. The article describes how most hospitals have a special wing for the wealthy, in which money can buy you a luxury private room complete with big-screen TV, plump cushions and an attentive nurse - and of course attended by the top surgeons. The VIP medical suites are thriving and they are one of the main ways that public hospitals can make money. A State Council decree in 2009 ordered them to take up no more than 10% of a hospital's beds, but critics say the VIP sections of hospitals are unlikely to be cut back. Caixin quotes Xu Shuo, deputy chairman of the Chinese Medical Doctor Association, as saying the suites are a symbol of the growing wealth inequality in China and will eventually have to close - or become a bridge between public and private medicine. However, critics say the private wings are simply too lucrative for both the hospitals and the doctors who work in them to disappear.

And in other news:

She's back ...
Mianyang's Corridor Doctor whistleblower Lan Yuefeng is featured in ChinaSmack. The site provides some pictures of the strike and public protest by her former colleagues who objected to her criticisms of the hospital from which she was sacked. Interesting comments from Chinese netizens and also western readers, most of whom side with the 'whistleblower', even though the staff say she is an attention seeker.

Smog and superbugs
Meanwhile, the smog continues in Beijing - and a story in the local news says that a Tsinghua University research team has found more than 1,300 species of microbes in it. Most of the bugs are harmless, but a small number are pathogens, according to the report.

Abandoned babies
And in Guangzhou, authorities are to announce new rules to deal with the "malicious abandonment" of babies after a dead baby was left outside a recently constructed "baby hatch" in the city, it is  reported. The baby hatch was set up by authorities to accept abandoned infants.  An autopsy will be carried out on the dead baby and if it is found to have had disease, the parents could be accused of intentional homicide, police say.

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.

Woman needs six stitches after argument with doctor

[Editor's note: there are three shocking things about this story, not just the alleged violence against the woman].

A woman in the Sichuan town of Yibin has needed six stitches for a wound sustained after a fight with a doctor over a dirty cushion. The woman named Chen says she got into an argument with a doctor in the X-ray department after she asked him to swap the cushion on the bench because it had  a bloodstain on it. The woman said that she took her 20-month old son to the hospital for a checkup when he had a cough and cold. When she took him into the X-ray room for a scan, she noticed the bloodstain on the cushion and asked the doctor to change it. However, the doctor refused and said "get on with it". When the woman took out some paper towels and started to clean the cushion, she says the doctor disappeared into  side room. She admitted she swore at him in frustration and then the doctor came back and swore back at her. The argument erupted and she said the doctor struck her on the head, cutting it open and causing bleeding, for which she needed six stitches. The woman said she was eventually faced with a bill for 3000 yuan in medical costs and she is demanding compensation from the hospital.
When the Dr Li was contacted at the Huaxi city Renmin Hospital he gave a different story. he said there were some bloodstains from a traffic accident on the cushion  that he had been trying to clean off, but the clinic was extremely busy and he was under a lot of pressure to examine a waiting room full of patients.  He said the woman called Li had been in an argumentative and volatile mood and had shouted and swore at him before chasing him into the side room. He said he had not hit the woman but had pushed her away after she started brawling with him, and she had fallen and hit her head.
 A hospital spokesman said he could not comment on the matter until a police investigation was completed.

Three things shock me about this story:

1. A dispute over a dirty cushion could result in a violent argument between a female and a male doctor.

2.  A woman would  take her infant with a minor illness like a cough and cold to a hospital and have the child exposed to high doses of radiation with needless chest X-rays.

3. The medical bill for a cough and cold (and stitches) could be as high as 3000 Yuan.

Violence in healthcare take a strange turn: nurse beaten by intern for questioning his advice

Healthcare staff in China have become inured to the threat of violence from disgruntled patients and their relatives, but this week a nurse has been subject to a violent beating from an unexpected quarter - an intern in her own department.
The nurse called Li Mei (pseudonym) says she still can't make sense of what happened, but she believes it was because she expressed doubt about the medical advice provided by a new intern in her department called Dr Du Mou.
A Shaanxi newspaper reports that the nurse was working in the internal medicine department of the Railway Hospital at Lueyang, Shaanxi alongside a male intern.
The nurse gave an interview to a journalist while she was lying in bed with an obvious red welt across her swollen face. She said the young male doctor had punched her repeatedly in the face, chest and stomach and also kicked her. She said it was because she had reminded him that his medical advice for one seriously ill patient was incorrect.
"As soon as I finished speaking he hit and kicked me. I was just stunned and dizzy and left with ringing in my ears," she said.
The nurse said she was now so sick she was unable to breastfeed her one year old child.
The local police station said they had sent officers to attend the incident, but when they arrived and ascertained what had happened, they were told by hospital management that this was an internal hospital disciplinary matter and they need not get involved. The head of the department confirmed to the reporter that an incident did take place but he refused permission for media to speak to the intern involved, who was still on duty.
The hospital director said the hospital managers said they were taking the incident very seriously and treating the injured nurse as best they could. An investigation would look closely into the events and would handle the matter gravely. The intern who hit the nurse was a recent graduate from medical school who had not yet passed his one year probation period. The intern said the nurse had sworn at him and cursed his family and he had impulsively struck out and hit her just once. The manager said interns did not have prescribing rights or the authority to give medical advice without supervision form a qualified doctor. He understood the two parties gave very different versions of the incident and the hospital was now investigating.

Doctor attacked for refusing drip | National roaming needed for medical insurance | Community HIV testing | Hand, foot and mouth disease surveyed

Doctor assaulted for refusing to put feverish child on IV drip
China's unscientific obsession with IV infusions for every malady has been brought into focus by an assault on a doctor at a Shenzhen hospital. In a widely reported story, it was said that a family attacked a doctor at a Shenzhen children's hospital when the doctor refused to arrange an IV infusion for a one year old child with a cold. The child had been brought into the hospital by his parents and was given oral medication after it was found to be feverish and diagnosed with a viral respiratory tract infection. However, the family were not satisfied with the oral medication and went back to see the doctor to demand their child be given an 'infusion'. When the doctor refused, the child's father smacked him in the face several times until the doctor was bleeding from the mouth. The attack was only stopped after the intervention of security guards and nurses. The attacker was taken into police custody where he will remain for at least three days while his case is investigated.

Health insurance won't work for floating population
China's goal of providing universal national health insurance is being hampered by the huge 'floating population' of migrant workers, a report has found. While more than 90% of the population are now covered by some kind of medical insurance scheme, the reality is that China's 240 million  'floating population' cannot take advantage of their insurance because it is only valid in their home town or province. This means that many migrant workers and their families from rural and regional areas face large medical bills that they cannot get any compensation for. IN some cases, floating workers will return home to take advantage of medical facilities where they can get some reimbursement, the report said. Integration of China medical insurance schemes is fraught with difficulty because different provinces and cities have different insurance schemes with different premiums and entitlements, the report notes. This means that local hospitals and health insurance schemes are unwilling to deal with 'outside people'. The solution may be some kind of 'national roaming' scheme for health insurance, the report concludes

Community HIV testing a hit
Rapid HIV testing is well accepted and detects many HIV positive people when offered by community clinics in China to high risk patient , a study has shown. In a trial of rapid HIV testing involving 42 sites community health centres in China, 23,609 patients underwent HIV testing. The positive screening prevalence was 0.41%, which is higher than in general hospitals (0.17%). Published in PLOS One, the study findings provide concrete evidence to support the involvement of community health clinics in the expansion of HIV/AIDS testing and case finding, said the researchers from the National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing.

Hand foot and mouth disease surveyed
China's largest ever study of hand, foot, and mouth disease has shown that it is most common in June in north China, whereas southern China has semiannual outbreaks in May and September. The review of seven million cases cases of hand, foot, and mouth disease showed the annual incidence was 1·2 per 1000 person-years, of which 2457 (0·03%) were fatal. The incidence and mortality were highest in children aged 12-23 months, according to the study published in the Lancet Infectious Diseases.

Hypertension more common among Mongolians
A study carried out in northern China has found that hypertension is more common among ethnic Mongolians. Mongolian and Han populations in northeast China. In a study of 4753 Mongolian people and 20,247 Han people, rates of newly diagnosed hypertension over a four year period
were 12.64 per 100 person-years for Mongolians and 9.77 for Han. The rates of awareness of hypertension were low for both Mongolians (36.5%) and Han (42.3%) Likewise, rates of treatment (13.1% vs. 18.2%) and control of hypertension (0.7% vs. 1.3%),were low among both Mongolian and Han population, the study in PLOS One found.