Three doctors in three different cities in China have been assaulted by their patients this month, two of them fatally. Wang Jun was struck in the head at a hospital in Hunan Province yesterday, passing several hours later. His death follows a knife attack on another physician in Chongqing and the stabbing death of a retired dentist in Guangzhou.
The spate of patient attacks is part of a years-long trend of violent “doctor-patient conflict” rooted in a national healthcare system that is spreading ever thinner. Partial marketization of hospitals and “buck-passing” healthcare policies in the post-Mao era are just some of the factors attributed to dysfunction, enraging patients who feel the medical system has failed them. The rise of a dishonest medical business nationwide was brought to the fore at the beginning of May with the online circulation of a deceased young patient’s bitter story of pursuing an ineffective cancer treatment he found at the top of Baidu search results.
In an interview with Initium reporter Zhang Yan, a pseudonymous doctor talks about the institutional pressures that drove him to leave the medical profession. Low pay, long hours, and total detachment from his patients are just some of the reasons “Wang Sen” felt as betrayed by the healthcare system as some of his patients. CDT has translated the article in full, which was first published by Initium on May 10.
A Mainland Doctor Tells His Story: After Ten Years, Why Did I Put Down the Scalpel?
Zhang Yan
Quitting at a hospital is just like quitting any government job in China. After his notice was stamped by 21 different departments, including human resources, finance, security, supplies, and the union, Dr. Wang Sen finally took off his white coat and left the operating table.
Before he quit last fall, Wang was exhausted, physically and mentally. He estimates that he performed over 2,000 surgeries as head surgeon, and had a hand in countless others.
There was too much work. Often times, he saw his patients for the first time when they were on the operating table. They would be under general anesthesia, covered in a sterile sheet, eyes closed, quietly waiting for Wang. He would pick up his scalpel, make an incision into the abdomen, and continue working for a couple of hours. After surgery, when Wang would see the patients again in the hospital, he couldn’t even remember their faces.
Born in 1982, Wang Sen has been a physician for ten years. He graduated from a prestigious medical school, got a master’s degree in clinical medicine, and landed a job in the top department of a grade 3 level A hospital in Beijing. From internship and residency, he pulled through the hardest years for a young doctor. He was promoted to attending surgeon and became the best surgeon among his peers in the same department. Everything was in his favor.
But he quit. The dangerous and unpredictable medical environment in China made him pessimistic. He says he has seen many “dark, hidden things.” After leaving his job, he traveled around the world, then moved to Shanghai, enrolled in art classes, and said goodbye to his old way of life.
“Everyone is like, why is it so hard to see a doctor, so hard to make an appointment? Why are doctors so cold and detached? So much antagonism…” Wang told Initium in a cafe in Shanghai. “It’s because there are faults in every part of the system.”
The following is Wang’s story as told to Initium.
“With limited time, the more patients, the better.”
Being a doctor in China requires not only that you perfect your medical skills, but also that you handle all kinds of administrative directives. Because public hospitals are state-run institutions—social service organizations established by the government with state funds—they must be managed by the government.
During the process of furthering healthcare reform, the government stopped expanding public hospitals in order to lessen the pressure on management. Hospitals started to emphasize the “turnover rate,” treating more patients in the same time and space. This would not only increase the income of the hospital, but also show advancement in managerial efficiency.
The art of medicine should be about quality, but now it’s all about quantity. The torrent of administrative directives quickly killed Wang’s curiosity and passion as a new doctor.
“When I first started, I was very passionate. I learned new things every day, from making incisions to performing simple surgeries. I slowly worked my way up to more complex procedures. I was excited to see some unusual cases. Back then, our operating room would stop taking patients after 4:30 p.m. When my colleagues and I had free time, we would eat dinner together or learn some new skills.
“Later, the hospital started to emphasize the ‘turnover rate,’ shortening the average length of stay for each patient and pushing us to make surgery more efficient. The average length of stay was like the turnover rate at a restaurant: the more patients you get in a certain timeframe, the better. But the quality of care went down. This stuff is good for the management people, like the president and the director, because shortened average length of stay is an example of their managerial efficiency. It makes them look good.
“What’s the goal of the hospital? To increase the number of surgeries by ten percent every year, which means no matter how many surgeries we did last year, this year we have to do ten percent more. If doctors fail to reach this goal, they won’t get their bonuses. So the result is that I have to continue to do more surgeries and shorten my patients’ length of stay.
“I used to do two or three surgeries every day, then it increased to five or six, sometimes even seven or eight. I would never have dreamed of this before. But nobody resisted. It’s just like the housing prices in Beijing. You used to think that 20,000 and 30,000 yuan per square meter was hard to bear. But now it’s 100,000 yuan per square meter, and you still have to buy it. You still have to take it.”
“A top doctor in China earns 50,000 yuan per month.”
It’s expensive to train a doctor in China. It takes seven to eight years for a medical student to become a licensed physician, and 20 years to become a chief physician. But the material rewards don’t always live up to expectations.
Healthcare is relatively cheap in China. Normally, the fees for appointments and treatment by doctors and nurses range from a few yuan to several dozen yuan. Doctors don’t have high salaries.
“As a doctor, there is a ‘step up’ every five years. It takes a medical school graduate five years to sign up for the attending surgeon’s test, and another five years to become an associate chief surgeon, then a chief surgeon. You should reach the highest professional rank around the age of 40.
“Doctors at all levels earn similar salaries. As an attending surgeon, I earned a base salary of 1,000 yuan. A chief surgeon would earn no more than 2,000 to 3,000 yuan on top of that. The rest comes from bonuses, which is the percentage you get from clinical work and surgeries.
“In my department, fresh graduates (young doctors) earn about 8,000 to 10,000 yuan per month. Chief residents earn a little over 10,000. Attendings are divided into junior and senior based on experience, and earn about 15,000 to 20,000 yuan, respectively. Associate chiefs and chiefs earn about 30,000 or 40,000 yuan. This money mostly comes from bonuses.
“There is a 60-year-old physician in our department. One day I saw his pay stub. His monthly salary was 50,000 yuan.
“Just think about it. A nationally renowned, ‘top ten’ doctor, earning only 50,000 a month, including bonuses.”
“The price of surgery was set in 1994. It hasn’t changed.”
The National Health and Family Planning Commission of China has proposed many times to reform the compensation system for doctors, and to increase their salaries. Wang also pointed out to Initium that the value of doctors’ work isn’t represented in the medical bill. The current price for surgery, set in 1994 and unchanged in 20 years, mostly covers the cost of supplies. Very little of it goes to the doctors.
“What we make from surgery is part of our bonus. Surgeons get about seven percent of the total cost of procedures. For example, removing a tumor may take five or six hours, and require four or five doctors, two nurses, and two anesthesiologists, about eight people total. The cost of the surgery is about 3,000 yuan, and seven percent (about 200 or 300 yuan) goes to the participating medical personnel. As the head surgeon, I get half of that, which is about 100 yuan, which I’ve worked five or six hours for. The attendings and assistants get less than that. Residents and interns even less. They take three percent of the seven percent, which is a couple of yuan.
“And, if you can’t increase the number of surgeries you perform by ten percent, this bonus is withheld.
“What’s even worse is that the state is going to launch the ‘single disease quality management’ policy (some diseases will have fixed treatment cost, also called a ‘single price guarantee’). Single disease management has its good and bad sides. We need to consider each separately. For example, if a patient has muscular tumors in their abdomen, regardless of whether it’s a hundred tumors or just one, and regardless of how difficult the surgery is, the price is capped at 3,000 yuan. If the cost exceeds 3,000, the hospital pays for the rest. So the hospital loses money on the procedure.
“The result is that we choose to perform laparotomies over the more advanced laparoscopic surgery, because a laparotomy only costs a couple hundred yuan, while laparoscopy is much more expensive. But we all know that laparotomies leaves big wounds, while laparoscopy only requires a few small incisions.
“But, even though these policies are fixed, people find ways around them. Doctors always find a way to make more money.”
“Orthopedics pays off.”
In China, many doctors make “gray income” by working for multiple hospitals and getting kickbacks for drugs and medical supplies. Some of this activity plays at the edge of the law. Strictly speaking, receiving commissions for expensive drugs is illegal, but it’s common in China’s hospitals.
A physician’s real income is related not only to their skill and seniority, but also to their specialization, their department in the hospital, and to professional ethics.
“Some sources of ‘gray income’ are legitimate. For example, if you give a lecture, you are paid 2,000 to 3,000 yuan. Others are ‘on the edge,’ like consulting or doing surgery for another hospital. The state now acquiesces to doctors working for multiple hospitals. In my field, the best doctors in the country earn somewhere between 10,000 to 20,000 yuan performing surgeries at other hospitals.
“Another type of gray income comes from kickbacks for drugs and supplies. For example, orthopedics require a lot of supplies. Say a patient has a broken bone. The doctor will put in a steel pin or plate to fix the fracture. And they get a commission for using these supplies. These surgeries take less time. Deft surgeons are able to finish them within one or two hours. Do you know how much a top orthopedic surgeon can make every year in China? 10 million yuan. For instance, artificial intervertebral discs used on a patient with slipped discs cost 50,000 yuan. And the commission paid to the doctor (by the medical supply factory) is 10,000 yuan.
“Kickbacks depends on which department you work for. Why does every doctor in China want to work in orthopedics? Because it really pays off. You can make a lot of money inserting catheters, too. The department I worked for, however, gets fewer commissions because we don’t use as many supplies. Even if we did, they are relatively cheap. The devices we use to stop bleeding and prevent adhesion may get us a couple hundred yuan or a thousand yuan.
“There are drugs and checkups too. Like I said, sometimes we lose money on surgeries. But during recovery, doctors can prescribe different types of drugs to boost the total cost.
“In my hospital, there are fewer doctors who take red packets. Some doctors are greedier and like to take red packets, but most aren’t. No one is one hundred percent confident in their skills, so if anything goes wrong, the red packet you took can become ammunition against you.”
“The pressure to research is like a sword hanging over your head.”
Doctors in China can’t stand out from their peers unless they “practice by day and research by night.”
According to the “Professional Technical Jobs Series” issued by the State Council in 1986, the evaluation of a physician’s professional rank and employment is tied to their research. Aside from soul-crushing clinical work, doctors have to allocate a large percentage of their energy to writing papers and applying for research grants. For example, in some provinces, if you want to be promoted to chief surgeon, you have to publish at least three articles in core journals.
“You are constantly on the spin in large hospitals. Except for people who are unusually terrible at work, most doctors have similar numbers (e.g. the number of surgeries they perform). So when it comes to determining who gets promoted, people compete based on research, on who publishes more, and who gets research grants.
“But doing research in China, very few doctors can publish in SCI (internationally recognized journals indexed by the Science Citation Index). Most published articles get zero citations. It’s just a resume booster.
“It’s a huge waste of resources. People would be better off if they just do what they are supposed to do. Clinical doctors could just focus on their clinical work, and if they have extra interest and energy, they can think about doing something else. In some other places, like Hong Kong, clinical doctors are evaluated by their own standards, which do not take into account their research.
“Research is like a sword constantly hanging over my head. It’s a mental shackle. Every time I think about it, it gives me headache.
“Even if you decide to stay out of it, to just do surgery and forget about research, you’d still feel bad when people get a couple thousand more on their pay stub every month than you do.”
“You learn how to deal with patients after you’ve become a doctor.”
Medical education in China focuses solely on professional knowledge, neglecting the human side of care. Wang feels that when he was a student he didn’t gain a good understanding of the social aspect of being a doctor. Many physicians can only provide technical care to their patients.
“Conflicts between doctors and patients only started over the past decade. When I was in school, it wasn’t as bad as now. And people didn’t really pay attention to it. In my fourth year of university, right before my hospital internship, a senior professor gave an hour-long lecture on how to communicate with patients. Before I started my job at the hospital, there was some training, but it really wasn’t that helpful.
“Communication with patients can’t be taught. You have to experience it or have a certain level of understanding. In some other countries, students can only apply to medical school after four years of university. They are in their twenties by then. They’ve basically come into their own, and also have some knowledge of the social sciences. They become doctors when they are relatively more mature. In China, it’s a sped-up system–people study medicine when they are fresh out of high school, and they deal with patients right after graduation. We don’t pay much attention to humanistic education.
“Of course, doctors are under a lot of psychological pressure. They are surrounded by a crowd of patients and their families, all day every day. They have two minutes for each patient, and there are people who cut the line. Then they don’t have much patience left. As time goes on, they become indifferent.
“On the other hand, some of my colleagues, I’d beat them up too if I were a patient. They have a terrible attitude. It’s like everyone owes them money.”
“It took me two years to resolve a medical dispute.”
In China, people treat healthcare as a consumer service. Patients think that because they have spent money, they deserve good results; if their outcome falls below their expectation, they will fight it.
Many patients with chronic diseases spend years seeking treatment. Their family is dragged down by medical bills. They start at village clinics, move on to county hospitals, then provincial hospitals, and finally to large hospitals in Beijing and Shanghai. There they die, their money used up.
As the “weaker” side, patients usually get more sympathy. Hospitals not only spend a lot of time on patient disputes, but also often end up financially compensating the family. To some extent, this practice has condoned violence. In China, many patients and their families think that if they threaten the hospital, they will get some compensation.
Hospitals have medical affairs offices that specialize in dispute resolution. These offices are usually located on the ground floor, so that if things turn violent, the doctor can jump out the window and escape. There are no computers, chairs, or side tables in these offices, because some patients’ angry family members may use them as weapons. A doctor working at a medical affairs office once told me that he would never pour hot water or tea for patients’ family, after someone once threw a cup of boiled water in his face.
“The hospital will always pay them something.”
Wang Sen was involved in a dispute, too. “In 2011, our department took a young urgent care patient. She had an ovarian cyst and was in pain. A type-B ultrasound showed that she had a mass on her ovary. But there was another small mass inside her ovary, a two-centimeter dermoid tumor that didn’t show up in the ultrasound. In surgery, I only took care of the large mass.”
“Because she was an urgent care patient, we didn’t thoroughly discussed her case before surgery. The smaller mass was discovered during a postoperative checkup. Then she started to argue. She confronted us on why we hadn’t removed it and demanded compensation of 260,000 yuan.
“10,000 yuan was for the surgical cost and 250,000 for mental damage. She said she was deeply depressed, that she couldn’t find a job, that her boyfriend left her.
“Then it entered into the mitigation phase. It took two years to resolve. She remained very polite every time she saw me, and thanked me for removing the larger mass. But she was poor, and she wanted the money.
“Because of the dispute, my promotion was delayed for a year. In the end the hospital compensated her a couple thousand yuan, but didn’t admit that the doctors had done anything wrong. They just wanted the problem to go away… As long as a patient accuses the hospital of malpractice, the hospital will pay them something.”
“I no longer dealt directly with patients.”
According to the “2015 Annual Report on Health and Family Planning in China,” the number of doctors under the age of 34 is shrinking. China Academy of Engineering fellow Zhong Nanshan said this year that roughly 20% of medical students no longer go into the medical profession after graduation. Wang Sen puts it more directly: he says none of his doctor friends allow their children to study medicine.
While China is losing doctors, it is gaining patients. According to the New York Times, stress, unhealthy lifestyles, and pollution are causing a surge in the patient population. The government projects that from 2000 to 2025, the patient population will grow by nearly 70%.
The workload that young doctors like Wang must bear is unimaginable. Yet their physical and mental health are largely overlooked by society.
“The first time making an incision, the first time stitching up an abdomen, removing an organ, extracting a tumor… They all make you happy, but only for a brief moment. What really sticks in my mind are the patients I had emotional connection with, not the sense of accomplishment from ‘what I can do.’
“I’ve seen many patients with terminal cancer. They have all kinds of reactions. I was really moved by an old teacher who was about the same age as my mother. She had cancer, and her husband had just had bypass surgery. They were taking care of each other. One day, the wife came for chemotherapy. We didn’t have a bed for her so she and her husband had to wait in the common area. That was an afternoon in the fall. People were silhouetted by the sun shining through the west-facing windows. I came out of my office and saw her standing on her husband’s feet as he held her from behind. They walked, one step at a time, like they were playing a game and no one was watching.
“Another patient was also in her later years. She had cancer and was in a bad mood, She often argued with other patients and their family. Back then I was in charge of her. Every time after I gave her an abdominal paracentesis, I would talk to her for a bit. One day as I was leaving, she suddenly grabbed my hand and wept. She said, ‘Doctor, please don’t leave. Other doctors don’t care about me, only you do. I don’t want you to go.’ She just held my hand like that… That patient was about the same age as my mom, and she needed me that much. That moment, I felt valued.
“The satisfaction that comes from experiences like this outlasts the happiness I’d feel from earning a little more money, or buying a slightly bigger house.
“But unfortunately, this kind of feeling occurred less and less often. When I became the attending surgeon, I no longer dealt with patients directly. Things like taking blood pressure, changing dressings, taking temperatures, and taking medical histories are all the responsibility of lower-level doctors. At best, I would see my patients every morning during rounds and after surgery.
“So what was it like in the end? It was working on a production line. I would do surgeries for other doctors all the time. Before surgery, I wouldn’t even know who the patient was or what they looked like. I’d just read the medical report and start. After surgery, I won’t even see the patient again before they were discharged… The emotional feedback was less and less. I felt like a meat seller.
“The stress was real. Sometimes I felt that I was completely irresponsible, but I didn’t know what else to do.
“When I first started in that hospital, the building was old, the walls peeling. Then they added a few more buildings. But the work environment didn’t get better. All those young doctors were crammed into a small room, fighting for computers to take down patients’ reports. There were only ten computers in a room, and 40 doctors would have to fight for them.
“But this wasn’t the biggest problem. If you can be a doctor in China, you won’t care how terrible your workspace is or how heavy your workload. Speaking from my seniority and experience, I’ve already gotten through the hardest part. But the most important thing is whether you have the same heart that you did when you first wanted to go to medical school. If not, you’d feel disappointed and lost. Then you are pushed by the tide. As time goes by, negative energy will push you to leave.”
(The case in this article only represents Wang Sen’s personal experience. It does not represent the opinion of Initium. Wang Sen is a pseudonym used to protect the interviewee’s privacy. The sequence of the interview was adjusted for clarity.) [Chinese]
Translation by Yakexi.
