Living in the shadow of violence: Why attacks on doctors keep increasing in China

On May 5th, Zhongwei Chen, a 60-year-old chief physician of stomatology in Guangdong, south China, just submitted his retirement application, planning to spend his later days from this year. While everything went wrong. Unconsciously, Chen was followed by someone when he was off work to home. It was one of his patients, who was treated by him 25 years ago, but now there was a sharp knife in this guy’s hand…

Merely within last month, there happened at least 6 violent attacks on medical staff in China. Those who save people’s lives themselves, at present, cannot protect their own safety. According to the data provided by the Ministry of Health, more than 17,000 violent incidents against doctors occurred in 2010, surging from around 10,000 five years earlier. As the situation described by the

Lancet, a medical journal published in Britain, “being a doctor has become a dangerous job in China.” Or more properly, they are in visibly rising risk. “This society is getting sick, very sick.” A doctor said, “everybody knows that the doctor-patient relationship in China is unfavourable long ago, and some alleged actions have been taken already, but why it is getting even worse?”

Pay more, expect more

Forcibly entering doctor Chen’s home, this patient perpetrator began to stab Chen in his face, stomach, arms and legs, over and over again…

Nobody knows that from when on, hospitals turned into battlegrounds, doctors and patients became hostile. Zhong Nanshan, former president of Chinese Medical Association, pointed that insight into the origin of the current crisis is essential to address the cause of patient dissatisfaction in China. Medical service, which is regarded as public welfare generally, appears to be a kind of consumer product in Chinese society.

Since the early 1990’s, China’s medical reform brought out the "drug maintaining-medicine" system. That is, public hospitals, which had been fully funded by the government, now have only a small number of financial support, in which way hospitals are forced to earn more money to cover costs by themselves. As the running of healthcare institutions largely rely on drug addition and medical services, there emerges a tendency of over-test, over-treatment and over-prescription for profit in China’s medical institutions, which leads to rising costs and reducing accessibility of medicine.

In some hospitals, the drug income accounts for 40%- 70% of their overall revenue3 , which pose a sharp comparison to many other countries, such as US, UK, Japan, etc., where there is a separation of prescribing from dispensing so that healthcare institutions don’t have direct self-interest conflict with patients.

But in China, it is quite a contrary. What is worse in recent years is that the proportion of government budget on medicine decreases continuously, falling from 36.2% in 1980 to 17.6% in 2004, which generated hospitals’ further commercialization and individual’s higher expenditure on healthcare. Accordingly, increasing spending encourages more and more Chinese residents treat doctor-patient relation as a consequence of consumption, and medical services become a kind of products which is provided by doctors. In general, commodity with higher price is expected to have better quality, likewise, with the rising spending on healthcare, patients hold higher expectation on treatment as well.

Once “consumers” are not satisfied with this “commodity”, they would put all the blame on hospitals and physicians, either demanding compensation or resorting to extreme behavior. “But life is not product, we promise to take 100% effort to save everyone, but we are not able to guarantee 100% success of the treatment.” Huang Yu, a nurse in Henan Province People's Hospital, said in frustration, medicine is a branch of life sciences, which involves limitations naturally, no matter how far it develops, it cannot achieve absolute accuracy and certainty.

However, a great many patients do not think so, they believe that there exist no problems that medicine cannot resolve.

Why more and more Chinese hold such a mindset?

Senior vice chairman of Chinese Hospital Association Zheng Xueqian gives the answer, generally, China’s authority tends to show the positive side of various social development, such as technologic, academic innovation. Similar to medical field, Chinese government and related institutions always give priority to the information about medical breakthrough rather than its limitations and relative riskiness, so that most Chinese residents, particularly someone with limited medical literacy, regard medicine as something that is solvable to any problem.

Doctors’ pain, media cannot see

However, as a Chinese saying one hand cannot clap, it takes two to make a quarrel. Commercialized healthcare system is not the whole picture, Chinese media is accountable for the growing tension between physicians and patients to some extent.

When police arrived at Chen’s home, he was stabbed more than 30 knives, lying in blood, while the killer had leapt from 18th floor, died. This extremely appalling violent issue, however, did not attract matching attention at once, which was in striking and deliberative contrast with another medical case that happened last month, a college student was died because of unverified treatment and flawed hospital management, which immediately became spotlight nationally.

Similar healthcare disputes as they are, media’s response, however, appeared to be entirely distinct due to different social identities of the victim. “Disproportionate negative coverage provokes and even sharpen the intensity between doctors and patients in China.”

Luo Wen, an experienced reporter who ever wrote that, “The reason why doctors are usually stigmatized is not only media’s lack of medical knowledge, but also their morbid thinking and reporting mode, such as preconceptions and presumption of guilt.”

Quite opposite to the medicine-related publicity of official institutions, social media mostly focuses on the malpractice and pitfalls of hospitals and medical professional, rather than their unfair treatment.

According to the research conducted by a Chinese scholar Pang Huimin, who collected and analyzed 89 medical-dispute cases conveyed by Chinese media between 2009 and 2011, 69% of these report started to accuse doctors and express sympathy to patients just before experts’ appraisal.

“We respect the supervision rights of media, but excessive negative report about healthcare venues and professionals, with continuous fermentation, will lead to extreme personalities and reactions of some individuals, which could result in medical injury.” A representative of Chinese Medical Doctor Association analyzed.

Referring to the White Paper on Chinese physicians’ status quo, over 84.31% medical staff thought the reason why violence against doctors happened is the imbalanced media coverage in 2014, which significantly increased from 53.75% in 2010.

Increasing work, decreasing talk

“When doctor Chen was sent to hospital, different stab wounds appeared nearly everywhere, his face was cut rotten, heel was cut off, while the fatal wounds were concentrated in the abdominal zone, where the gut has come out and most organs were crushed terribly.” A nurse colleague described.

In the course of Chen’s rescuing, almost all of the medical colleagues stayed outside the emergency room praying for him, worried and shocked as well.

“This murderer has come to Chen for several times before, as he claimed that his porcelain teeth, which were treated by Chen 25 years ago, discolored and demanded compensation, otherwise both would die.”

One of Chen’s colleagues explained, in clinical practice, the service life of porcelain teeth is around 10 years averagely, however, this patient complained about the discoloration after more than 20 years and put all blame to the doctor, it is ridiculous.

While why this unreasonable accusation turns up? We need to think about it seriously. “Communication between physicians and patients nowadays decreases sharply,” Mi Changfa, director of a private hospital, analyzed.

He said since the increasing quantity of sick people and overwhelming medical workload in recent years, doctors don’t have sufficient time to communicate comprehensively with individual patient, “experience a long wait for a short appointment”, which is a typical description that happens on every patient in China’s hospital, “it is easy to cause deeper misunderstanding and even resentment between them”.

Where does the high load come from?

One of the most important explanation is the everaccelerated population aging in Chinese society. According to the official data, it shows that by the end of 2014, the aged over 60 years old in China has reached 212 million, accounting for 15.5% of the gross population. And it is predicted to crest by the middle of the century, with more than 400 million old people living here.

“The prevalence rate gets higher with age, which means that the medical needs increase accordingly,” interpreted by Song Jian, professor of Population and Development Research Center in Renmin University of China. He thought this is the main reason why the outpatient quantity and physicians’ workload have surged during the last few years.

Medical justice, protect who?

On May 6th, doctor Chen’s rescue remained under way. “His blood has been changed for a few times, but a variety of biochemical indicators are not optimistic.”

Zhang Yi, a doctor colleague of professor Chen, said, “but all of the rescuers are making all efforts to save him.”

However, after the continuous rescue up to 43 hours, miracle did not appear.

“At the clinic, I have to make definitely sure that there is nobody behind me," a doctor post online after Chen’s case, "I am alert to everyone at present.”

The growing tense relationship and disputes between physicians and patients has been seen by everyone in China, nor are Chinese doctors unique in facing such conflicts, however, the frequency, viciousness and severity are unparalleled.

The flawed medical justice system should, undoubtedly, be accountable for this deteriorated situation. For the sick, there is a lack of institutional path addressing their rights. In spite of the establishment of appraisal panels for medical liability, it is often complained to be either ineffective or inefficient. The limited recourse for dissatisfaction promotes those already low-legalconciousness patients and their families to resort to violence rather than those justice administrations, once they are confronted with some trouble.

On the other hand, deficient legal safeguard for medical staff and indulgency of related patient perpetrators also provoke the rise of violence. “Never fight back” is a basic request for medical staff. In practice, quite a lot medical attacks are even hide by relevant authorities, in order to minimize the negative influence on medical system, which protects those perpetrators from punishment and encourages potential violence as well.

A nurse, working in Modern Chaoyang Hospital, says: “We don’t respond to verbal attacks and just hope it doesn’t get any worse.” A doctor colleague, standing nearby, is worried that there are no extra police in hospitals. “Yes, I’m scared,” she says, “but what can we do?”

Sick society, how to treat?

The increasing occurrence of violence against medical personnel has a close association with politics, economics, legal system, contemporary culture and many other factors. It is not generated in a day, and likewise it cannot be solved in a day. “Not only the healthcare system resembles a patient who is waiting for surgery, but the rationality, honesty and inclusion of the society need thorough treatment as well.” Young dermatologist An Ran wrote down these words in his article.

Basically, violence against doctors is the confluence of several interconnected systemic defects, 185 only if China’s bold vision for healthcare reform is fully realized that which can be addressed properly. In 2010, China's gross expenditure on healthcare only accounts for 5.1 percent of GDP, which is lower than the average of all middle-income countries. “There is a huge gap between economic development and healthcare input in Chinese society, therefore, increasing government funding and lightening individual burden of medicine tend to be imperative in China.”

Chen Zhiwei, an attending physician suggests, only when medical services turn back from commercialization to public welfare, the public will give back its kindness.

Media environment, moreover, as the constructor of public perception, not only have the right to expose the dark side of the society, but have the obligation to spread positive emotions as well. “The relation between doctor and patient is one of the strongest trusteeship, which should not be mixed with deception and hostility, and it is crucial to express this faith to public by media.” Zheng Xueqian said.

In addition, a well-organized society needs to be maintained by responsible institutions and effective legal system. “We have established relevant organizations for medical reliability, but we need more comprehensive and effective management to make them a real promoter of social justice for both patients and physicians.” Doctor Mi stated.

More specifically, in the respect of the sick, the primary step is to enhance their legal consciousness through activating relevant organizations, streamlining related procedure, so that patients could strengthen their courage and confidence to win a legal claim against even a big hospital; In the respect of medical staff, formulating mature risk assessment indicators, improving security system are practical measurements to rebuild perceived safety of healthcare staff.

To tackle this chronic sickness of Chinese society, rekindle doctor-patient trust between doctors and patients needs full engagement of pervasive actors. In the evening of May 7th, thousands of citizens organized a memorial for doctor Chen spontaneously, glowing candles lightened the whole Hero Square, also lightened the way to paradise.

“This is the only thing we can do for professor Chen.” A colleague says, with sad resignation.