Rank-and-file doctors caught between an unforgiving system and untrusting patients.
Photo by Kuang Da
By HUANG Hua
It was ZHANG Qingwen’s fourth meeting with the same patient. At each previous appointment, he carefully explained to her family why she shouldn’t use the drug they requested. When she brought it up again this time, he was at his wit’s end.
"At least, they aren’t saying I take kickbacks from another drug maker," Zhang said.
Doctor-patient relationships are fraught with tension, and such difficulties have come up more frequently since the healthcare anti-corruption campaign became headline news last month.
Every day in Zhang’s WeChat groups, doctors talk about another department head being investigated. At his hospital, the largest in his city, everyone has been told to return anything they have received "before investigators find you.”
All this feels very distant to Zhang, who graduated from medical school only two years ago, and from some points of view could even be considered "impoverished." Everywhere in the world, this is the most arduous time of any doctor's career. Kickbacks aren't really a feature of Zhang's landscape. “I haven’t seen a cent,” he said. “Reps don’t bother with junior doctors.”
In China’s hospitals, doctors are ranked by four levels of seniority – chief physician, deputy chief, attending, and residency. By some estimates, 80 percent of the nearly 4.3 million registered doctors belong to the lowest two, who have no say over hospital finances. They perform the day-to-day tasks of patient care. They prescribe whatever is on the hospital list.
They are also at the sharp end of the inefficiencies of the healthcare system. Verbal abuse and even physical assault from patients are common concerns.
“The system is like a pyramid. A small minority at the top gets recognition and money. We at the vast bottom get a ton of work,” said XU Kai, a sixth-year attending anesthesiologist at a 3A hospital, the highest rank of China's public hospital system.
It was well after midnight when he finally got some time to talk to Jiemian News. Because of the anti-corruption campaign, chief surgeons at his hospital are all operating locally instead of traveling to more lucrative locales. Xu, as a result, is suddenly getting double and sometimes triple his usual amount of work.
“Chiefs do 5 percent of the job. They may show up for ten, twenty minutes. The rest is left to us rank-and-files,” he said. “But chiefs are paid the most.”
Doctor’s pay differs widely by rank and specialization area. A chief oncologist, for example, makes roughly 288,000 yuan (US$39,500) a year, according to data collected by the medical-media company Dingxiang Doctor. Not counting consulting fees, travel perks, or any forms of “thank you money” that are now supposed to be returned, this is almost twice as much as an attending oncologist (167,000 yuan) and three times that of an attending generalist (115,000 yuan).
Morale is consequently quite low among junior doctors. At Xu’s hospital, it is not uncommon for residents and attendings to work 20 hours straight. Forty-hour shifts are not unheard of. Promotion is not a choice, it's a necessity “unless you want to be on night shifts for the rest of your life.”
But climbing the ladder takes patience, planning and a lot of luck. The path is even less clear for doctors at small hospitals, who also happen to be the most overworked and underpaid of all.
By meeting all the publication requirements while powering 20-hour shifts, you can make chief physician in about 15 years. Promotion is much more about writing articles and getting them published than it is about patient care. Hence numerous accusations of academic fraud.
But in the ultra-exclusive world where decisions are made – department heads at 3A hospitals, for example – getting along with the right people and protecting their interests once you get on the boat is paramount.
Almost everyone agrees such a system breeds corruption. Profiteering is a reaction to and delayed compensation for years of thankless toil. An anti-corruption drive can shake the power dynamic at the top, but it won't do much to improve the conditions of rank-and-file doctors. And may even affect the medical outcomes of their patients.
Headlines make people believe that patients do not receive the best possible treatment. And that it's because hospitals and doctors are in cahoots with drug companies. But as a front-line doctor, Zhang Qingwen feels that, more often than not, it is the insurance company that stands in the way.
State-run insurance does not offer all drugs for all conditions to everyone. Budgets are not unlimited. The juggling act is a very complex one. As a result, patients who cannot afford to pay have to take what they get. If a patient's condition develops, they may qualify for a different drug.
It's not a peculiarly Chinese way to run a health insurance scheme. It's the standard global model. But in this case, doctors are accused of delaying treatment to make money for themselves and the hospital.
The upset patients and their families rarely have any ethical or legal basis for their anger, but angry family members are not busy filing complaints with the appropriate authority. They are screaming at, or even slapping the doctor's face.
“The setup favors anyone with money to spend on their treatment. They can pay for whatever drugs they want, with their doctor's approval,” Zhang said. “The majority of patients, those who rely on government insurance, have to take whatever has been approved.”
Talking to his patients, Zhang knows firsthand how insurance affects them. Since last year, many municipal funds have reduced coverage and asked for higher premiums, triggering complaints and even protests in some places. As the population ages and the birth rate falls, only root-and-branch reform will be enough.