Last Friday afternoon, Wang Hao, a young internist at the First Affiliated Hospital of Harbin Medical University in northeast China, was brutally murdered by a disgruntled patient. It was a spectacular crime, but it was not an unusual one: Violence against doctors, including murder, is commonplace and reportedly increasing. In 2006, the last year for which detailed records on patient-doctor violence was reported publicly (including violence perpetrated by patient family members and friends), the Chinese Ministry of Health stated that 5,519 medical personnel had been “injured” in disputes -- a substantial increase over previous years. And on March 29, the China Daily cited an “official source” who said that in 2010, 17,000 violent incidents took place, affecting roughly 70 percent of all public hospitals in China.
Why so much violence against one of the caring professions? Chinese media, and microblogs, are filled with theories.
In 2007, Xinhua, the state-owned news agency, explained it as a function of “patients' families and friends [becoming] more likely to use violence to vent their rage over hospital errors.” There’s some truth to that. China lacks a credible and independent medical malpractice system to determine compensation for medical errors. But that’s just the beginning. The more critical issue relates to the comically low compensation medical professionals receive (the starting salary for a doctor is around $500 per month). To supplement their income, they legally receive commissions on prescriptions and medical services. On Thursday, Shanghai media reported that the city’s doctors also commonly notify funeral homes of impending patient deaths in exchange for kickbacks.
Chinese patients often enter a hospital prepared to pay bribes for the care that they need. I’ve personally witnessed a “tip” handed to a doctor in advance of a surgical procedure at a top Shanghai hospital. They can also be tricked into undergoing unnecessary but revenue-generating procedures. Three years ago, for instance, at another Shanghai hospital, I was told I should get a CT scan so as to better understand the causes of a sinus infection, and then asked to purchase a Percocet prescription to manage my pain. I didn’t need either. Combine this norm, however, with crowded waiting rooms, high and expensive hurdles to see specialists, and a pointed lack of means to civilly contest malpractice and one can see why resentment against the Chinese medical profession has boiled for decades.
Last Friday’s murder, even in the context of other Chinese patient-doctor murders, doesn’t reveal much about the scale of patient bitterness in China. That proof is provided by an astonishing online poll posted by People’s Daily, the official mouthpiece of the Chinese Communist Party, a few hours after news of the murder went viral in China. The now deleted survey (posted as an attachment to this article) asked readers to express their feelings about Wang Hao’s murder by clicking on emoticons symbolizing feelings ranging from anger (a red fuming face) to happiness (a yellow smiley face). Shockingly, of the first 6,161 readers to respond to the poll, 4,018 --- 65 percent -- chose happiness. Anger came in a distant second with 14 percent. The third choice, sadness (a teary, yellow face) received 6.8 percent.
Somebody on the People's Daily’s staff had the good taste to pull the survey down before the end of the night. But the damage was done: Chinese netizens saved screen shots of the poll and tweeted it. By the next morning “4,018” was a searchable term on Sina Weibo, China's most popular microblogging site. The survey results were retweeted hundreds of times along with commentary on the coarsening of Chinese society, the low esteem in which doctors are held -- and what to do about both problems. Xu Xiaoliang, a human resources consultant in Beijing, was one of thousands who have commented via Weibo on the 4,018 happy faces since the news broke. On Tuesday, he posted:
Internet users are happy, of course, not for the innocent medical intern’s death, but instead happy as a kind of vengeful catharsis against the professional ethics of damn doctors who receive red envelopes [filled with cash] and kickbacks! Black hearts and low morals are not natural to doctors, rather the current situation is caused by commerce and imperfect regulations!
Predictably, a search of China’s microblogs will not turn up any doctors willing to defend the acceptance of bribes and commissions on prescription sales. However, a few brave doctors have taken to Sina Weibo to defend their profession – or at least themselves. Of these, Zhang Rongya, a gynecologist at the elite Peking Medical College, offered a personal appeal that’s been re-tweeted more than 4,000 times and generated more than 3,000 responses, most of which are supportive:
These days I’ve been thinking about this question: why did I choose doctor as my career? Why did I oppose my family’s hope and choose this occupation, which is arduous but fruitless and garners so much criticism? Medicine was not my major when I first went into Tsinghua University, but I switched my major because of my deep love for medicine and a desire to heal the wounded and rescue the dying. However, I feel a deep hurt in my heart now. I need much encouragement and affirmation, or I’m afraid that I simply can’t stick to it.
In fact, despite the 4,018 smiley faces left with People’s Daily, the vast majority of online comments – including comments to Zhang’s post -- are supportive of doctors. That noted, perhaps the best encouragement, if not consolation, for Zhang is that somebody in the Chinese government has been listening to the online public uproar and doctors’ laments.
On Tuesday, with impeccable timing, China’s Ministry of Health issued a directive to “effectively maintain law and order at medical institutions.” In addition to tighter security requirements, it encourages the development of dispute resolution programs -- though, notably, it gives no guidance on what those should look like. And, on Wednesday, the local government in the southern city of Shenzhen announced that it was immediately implementing a program that would simultaneously raise the medical consultation fees it pays to doctors while prohibiting hospitals from marking up the price of pharmaceuticals sold to patients. This separation, Chinese media reports suggested, will reduce the incentive for doctors to prescribe unnecessary treatments.
Still, it’s hard to believe that any amount of concessions and regulations will make much of a difference to ending patient-doctor violence that’s based on a generational mistrust of the medical profession. Consider, for example, the deeply seated biases embedded in the following dark parable now circulating on Weibo. It stars a doctor and a low-level municipal inspector, perhaps the only Chinese profession held in lower esteem by the public than doctors due to its reputation for being -- like doctors -- a destination for bribes. However, the parable suggests that the doctor -- unlike the municipal inspector -- maintains a lofty, out-of-touch opinion of himself, despite the hatred directed his way:
Midnight, an emaciated man is sitting alone, drinking, and mumbling to himself: "Who did we doctors offend? Why were people happy after that doctor was slashed to death?" Suddenly, a robust fellow sat next to the man, grabbed the bottle of wine and drank it up, with a sigh: "Only we municipal inspectors can understand you doctors!" The emaciated man was silent for a little while and then suddenly smacked the robust man in the face: "Go to hell, heretic!"
It’s an ugly sentiment, but one that China’s medical practitioners and reformers are going to have to confront if they want to bring an end to this most unique of violent Chinese crimes.
(Adam Minter is the Shanghai correspondent for the World View blog. The opinions expressed are his own.)
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