Reflecting After the Pain: Rethinking How to Reform Healthcare in China

After every incident of violence against doctors, physicians ought to draw lessons from these bloody experiences and reflect on how to change the current medical system, improve the quality of service, and raise their own professional safety.

Healthcare in China is spinning out of control, and a runaway medical system harms both doctors and patients.

There are many reasons why Chinese healthcare has lost control.

In my view, the foremost reason is that when New China was founded, the "founding fathers," in designing the political and medical systems, lacked foresight; the root causes of many of China's present-day problems can be traced back to that moment.

Seventy years since the founding of the nation, the rule of law in our country is still very weak. We remain in a state where laws exist but are not enforced. Over the past decade I have dealt frequently with hospitals and health administration departments, and everything I have seen and heard shows that the rule of man prevails over the rule of law. In our country, trying to accomplish something according to the letter of national law is almost a joke; you have to rely on personal connections to get anything done.

What is the use of having laws in such a society? Precisely because fairness and justice have been lost, many people at the bottom of society approach social stability with a mentality of mutual destruction. They follow the "blood-for-money law" summed up by Mr. Wu Si, replacing the laws and regulations that everyone ought to share with all kinds of hidden unwritten rules.

If we study the violent incidents against doctors that have occurred in China over the years, we find that those who commit such violence share far too many similarities with most criminal offenders and serial killers. They stand at the bottom of society, their lives are full of setbacks, their hope of changing their fate is slim, and they hold an attitude of extreme indifference toward their own lives and the lives of others—which is why they perpetrate all kinds of vicious incidents.

After the violent attack on a doctor at Civil Aviation General Hospital, many people forwarded to me the newly passed legal provisions on preventing medical disturbances. After reading them, I remained noncommittal.

I am not one of those youngsters who just entered medical school; I am a middle-aged person with rich social experience, and clauses that cannot solve the problem do not move me. I believe that before China's broad social environment undergoes fundamental change, doctor-patient disputes cannot be improved by a few legal provisions.

Moreover, I strongly suspect that in the near future there may occur even more malignant incidents triggered by medical disputes. A hospital is a place where crowds gather; once a major crime occurs there, the scene will be horrifying, and casualties are certain to be heavy. Forgive me for speaking ill in advance: unless China's broader environment and its medical environment change, such vicious incidents will happen sooner or later. A few years ago, some extreme suspects attacked unarmed primary-school pupils and kindergarten children—those are warning precedents worth heeding.

As someone who has studied medicine, I know that preventing disease is more important than treating it. Solving social problems is no different from treating disease: prevention matters more than punishment. Punishment does not reduce crime; improving the social environment, raising people's happiness index, and reducing the population living in poverty can ease the extreme emotions of those trapped in hardship and lower the crime rate.

Do we have the courage and the ability to improve the whole social environment? Can we build a society with a high harmony index, a small gap between rich and poor, and a sound rule-of-law environment? Can we rebuild a fair and just society? This is a question worth everyone's reflection. The so-called doctor-patient dispute is merely a side-profile of a deformed society.

"When the people no longer fear death, why threaten them with death?" In the perpetrators of the repeated attacks on doctors in China, almost none expected to survive. To a desperate man, legal provisions are nothing but a scrap of paper. What we really need to do is make people unwilling to become desperate outlaws. Only when their lives have something to look forward to will they choose not to become outlaws.

What truly angers me is not the desperate outlaws who attack doctors, but the fact that this great nation of ours, while singing and dancing to the tune of an era of prosperity, continually produces such desperate outlaws. These outlaws reach the point of desperation for deep social reasons.

When everyone complains about how hard and expensive it is to see a doctor and denounces medical disturbances, they are all just like ostriches, avoiding the fundamental institutional, political, and livelihood problems—avoiding the distorted ecological problems of our civilization caused by the loss of fairness and justice. Why is the rancor among China's common people so deep? Both those in power and the general public should reflect on this.

So, colleagues, those of us who study and practice medicine cannot live our whole lives as if in an ivory tower. If we know nothing about the broader social environment, we will lose the vigilance we ought to have. We must understand that our current social environment is rather harsh, and that part of the population is in a state of extreme irritability. A poor practice environment is an objective fact; in such an environment we need the ability to identify extreme individuals and prevent attacks on doctors. The media's one emotional campaign after another cannot solve the root problem; after the sentiment fades, we still have to face patients of all kinds and unknown origins.

Medicine has never been merely a technique for curing disease and saving lives; medicine touches a very broad sphere. Doctors need good powers of discernment and coordination, as well as a strong sense of risk and the ability to avoid risk. Without these abilities, and without sufficient vigilance against potential danger, accidents can easily happen to us.

China's current problems of "difficult and expensive access to medical care" are a false proposition. Compared with countries around the world, both the quality and the price of medical services in our country are very affordable to ordinary people. Yet ordinary citizens still feel that seeing a doctor is hard and expensive, while the income of ordinary doctors is not high either.

Why is this so? It is because when New China was founded, a socialist system was implemented. The government gathered doctors who had been scattered across society into hospitals and set very favorable medical prices. As a result, for decades our people enjoyed publicly owned medical services that were far cheaper than those of today.

Nowadays the state encourages the development of the private economy, and all sectors of society are desperately trying to get rich; prices and housing have been bid up, and no one gives doctors free housing or free rice, oil, and salt. Yet ordinary people have grown accustomed to cheap medical care, and when they are asked to pay far more than in the past for treatment, they begin to complain.

I am forty years old this year. I have personally witnessed the tremendous changes in Chinese society over these years, but the slowest-changing—and most absurdly changing—field is medicine. For a long time the consultation fees of Chinese doctors have been pitifully low; the registration fee for a Chinese doctor is an out-and-out insult to Chinese doctors. The Chinese government and the Chinese public have simply ignored the effort doctors put in during years of hard study, and have exploited doctors for many years.

While we impose humanitarian sentiment on doctors, we place them in an extremely awkward position: to feed their families, they have to survive on income beyond consultation fees. Moreover, because doctors are concentrated in hospitals under unified management, Chinese doctors also have to submit to hospital administrators. In recent years there has also been a push to privatize hospitals, so hospitals now have an additional capitalist background.

Probably only a few countries in the world, ours included, have this phenomenon of large numbers of doctors concentrated in hospitals rather than working as independent practitioners—from what I know, in many countries doctors practice freely in their own apartments or clinics. Before liberation, the four famous doctors of old Beijing were all independent practitioners; they did not work in hospitals but ran their own medical residences at home or in their clinics. They built their own personal brands, and to protect those brands, doctors could automatically adjust the price of their medical services according to patients' evaluations.

Today, independent practitioners are regarded by patients as quacks, and most patients are full of suspicion toward them. Doctors who are independent practitioners will strive to improve their medical skills and service attitude, whereas doctors on a hospital payroll dare not defy their superiors' orders. In the end, China's medical enterprise does not operate according to market rules but according to the wishes of the leadership.

In recent years, some businessmen who are not medical professionals have begun to reach for the big cake of private healthcare. If I were willing to meet with some of my business-minded merchant readers, I could hear high-sounding talk every day about how to break into the big health industry; many people are trying to recruit me to cut a slice of that big cake.

I know a person who used to bribe officials to land construction contracts and was even punished by the government for bribery. Then he suddenly developed a brain tumor, and his mind opened wide: he decided that the medical industry was a fat prize. After mulling it over for a few months, he could talk of nothing but the big health industry. That is how he switched careers into medicine, and within those few months he dared to declare that he had found an effective anti-cancer method and conquered cancer.

Unfortunately, his brain tumor recurred not long ago, and I do not know how he is doing now. I think it is better that such a person lacks the ability to make trouble; if he were capable of it, who knows how much muddy water he would stir up in the big health field.

I have worked with some Japanese and American doctors. Because of the language barrier I did not communicate much with the Japanese doctors, but I communicated quite a lot with the American ones. Their sophisticated business thinking impressed me greatly, but their medical skills and medical ethics were equally admirable. Our Chinese doctors are ashamed to promote themselves and ashamed to manage their personal brands with a business mindset.

A doctor like me, who is good at using self-media, is also easily accused of being too utilitarian—sorry, I will probably be this way all my life. Because once I build my own personal brand, I can free myself from the bonds of hospital management and practice medicine according to my own heart throughout my career; I will not have to live at the mercy of others, nor will I have to, under the tyranny of my superiors, exploit patients regardless of their lives and feelings and make enemies of them all.

A dermatologist friend once said to me: medicine can make money, but it should make slow money, not fast money. His words hit the nail on the head. Doctors also have families to feed and should not be ashamed to talk about making money. Patients do not resent doctors making money; for the doctor who treats their illness and saves their life, patients are genuinely willing to express gratitude with money. Just don't make it too black-hearted, don't suck the patient dry. Make reasonable money, and no patient will raise a knife against a doctor.

But which hospital does not want fast money? Making fast money means over-exploiting patients; after over-exploiting patients, how can frontline clinical doctors not be in dire peril? I have worked in a hospital, and as an administrator at the hospital-director level that many doctors envy. I resigned because I could not bear the capital side's pressure to make fast money.

For those of us who intend to devote our lives to medical service, we care about our personal brand, our image, and our safety. It is only the profit-hungry investors who care about quickly recouping their capital.

Not long ago, the director of a private hospital in Beijing—originally a public hospital later acquired by private capital—committed suicide after clashing with the investors over management rights. When I saw that news, I felt deeply for him.

I myself chose resignation rather than suicide. I think that director who killed himself was foolish: if this place won't keep me, there is always another place that will; just move elsewhere to practice medicine. A physician is a craftsman; a fat purse is not worth a single skill. If your medical skill is solid, why fear that you cannot survive? Why take your own life?

According to news reports, after the hospital was acquired by the investors, the investors—who had lost disastrously on the stock market—quickly staged a comeback, because the hospital had become a remarkably generous cash pool for them: under the businessmen's management, the hospital was fucking amazing at making fast money. People curse hospitals as black-hearted, and hospitals truly are black-hearted. It is just that the pitiful frontline doctors have become the scapegoats of the black-hearted investors; the big bosses face no risk of being cut down, while frontline doctors can easily lose their lives.

The core resource of medicine should be the doctor. We have talked emptily for so many years about respecting doctors, yet at the same time we keep doctors penned up like animals in a zoo, restricting their right to practice freely and their clinical discretion with all kinds of rules and regulations. Truly lamentable!

Most doctors are not foolish; in the course of clinical treatment they can sense which patients are safe and which are dangerous, which are well-off and which are hard up. As long as doctors are given freedom, they can handle things very well. The state need not cling so stubbornly to a paternalistic management model; that only makes the medical environment worse and worse.

Among the millions who study and practice medicine in China, I am one of the few odd ones; most doctors are bookworms bound hand and foot by the system. I am the monkey that escaped the cage, though of course I also worry that the Tathagatas will press monkeys like me back under the Five-Finger Mountain.

Our central government now seems to have recognized this problem; they are willing to let the monkeys return to the mountains.

But, first, social stereotypes have already formed. For decades top-tier Grade-A tertiary hospitals have gathered famous doctors while grassroots hospitals lack quality resources, and independent practitioners have been slaughtered almost to the last man. This over-concentration of medical resources has already made Chinese healthcare suffer unbearably. The healthy medical ecology that naturally formed over thousands of years of Chinese history has been severely wounded under government regulation, and it is not easy now to change the public's habits of seeking care.

I estimate that even if the government liberalizes policy now, restoring a relatively healthy medical ecology will still take one or two generations. If the medical ecology itself is unhealthy, how can it safeguard everyone's health?

Second, most grassroots civil servants in China have long grown accustomed to lazy and inert governance. Not long ago I saw People's Daily criticize a local industrial and commercial bureau that, out of sheer laziness, actually drove a well-run alcohol-manufacturing enterprise into bankruptcy. The business owner was literally worked to death by the endless "license processing," dying at age 57, and hundreds of people lost their jobs. Such phenomena are everywhere at China's grassroots level. No matter how good a medical policy is, when it meets the hands-off, inert lords of the grassroots government, it can only gaze at the ocean and sigh.

I am not a greenhorn fresh out of medical school, so a scrap of paper from the government cannot flatter me into happiness. Nor am I an angry youth who only knows how to shout about killing; I deeply understand that China's reform has now entered deep waters and cannot be changed just by shouting a few slogans. Let us hope that, as time goes by, our society can undergo fundamental change at a deep level! And let us hope that fewer people are driven by the misfortunes of life into becoming desperate outlaws. I sympathize with the murdered doctors, and I also sympathize with the desperate outlaws whom society murdered long ago.

As a practitioner of Chinese medicine who cares about the nation's economy and people's livelihood and about the development of medical services, I very much hope to promote medical reform peacefully, and very much hope that the high and mighty in the court will grant those of us who love medicine a way to live, restore the doctor's autonomy, loosen the rope around our necks, and let us control our own destinies.

The real murderer who strangles doctors is the system, nothing else.