Monday, 29 February 2016

How pharma companies get their drugs prescribed in Chinese hospitals


I wouldn't be exactly "leaking state secrets" by revealing that China's hospitals expect bribes from pharma companies in order to stock and prescribe their drugs. The practice is so well embedded and accepted that it has its own name: "pharmaceuticals feed the hospitals". And this month there is an excellent article from UK-based Chinese researcher Dr Yang Wei, from the University of Kent, which explains how the whole process works from pharma company via hospital pharmacy to the prescribing doctor. To explore the details, Dr Yang interviewed four doctors, five hospital managers and four pharmaceutical industry managers from Shanghai. Broadly speaking, the problem of overprescribing and corruption in prescribing arises because China's hospitals get very little or no financial support from local government. They are essentially self supporting. Despite its increasing prosperity, China spends only a tiny proportion of its GDP on health (about 5%, less than Afghanistan) , and hospitals see very little of that money. As one manager told Yang:
"I think the biggest problem is that there is not enough money for healthcare sector. It is
also related to whether health care is a policy focus of the local government. I remember
that in the past the government would allocate certain percentages (of their budget) to
subsidise healthcare sector, but now it seems there is no such policy… At least in my
district, hospitals are almost financially independent."
Hospitals face rising costs, rising demand for services and yet the fees they can charge for services are capped by order of the central government. This means many hospitals are in serious financial difficulty, running into debt and unable to pay their bills for supplies. The problem is especially bad for regional and rural hospitals faced with the double whammy of wealthier patients preferring to go to city hospitals, while the local government is starved of funds due to migration of the working population to the cities.

The hospitals must therefore obtain revenue from the sales of pharmaceuticals and medical services. To ensure they receive a fixed and predictable income, the senior managers set financial and servicing targets for each hospital department. These department managers in turn set targets for individual doctors.

As one hospital department manager said:
"We have targets for each quarter, and we have to fulfil it to generate enough profits. There are regular meetings in the hospital. We discuss which medical department is not doing well in terms of meeting targets. We, doctors, all want to generate profits, and the hospital wants to generate more profits as well."
The financial revenue performance targets are thus written into the doctors' contracts, with a financial bonus dependent on meeting those quotas. According to the doctors interviewed by Yang, a typical bonus for a junior doctor is around Y2500 quarter, for a doctor whose basic salary is 5000 a month.

However, the bonuses depend on the level of seniority and also on the speciality. Doctors working in surgery and orthopaedics can earn much higher bonuses because they see more patients and can offer more interventions and services, Yang notes. Conversely, doctors in specialities such as paediatrics have a lower income from bonuses as they tend to prescribe less.

Doctors see nothing wrong with earning bonuses for overprescribing or overservicing, because their basic salaries are so pitiful for their high workload and high level of expertise:

"(Being a doctor) is a job that requires years of training and deals with lots of risks. But
their salaries, compared with their foreign counterparts are quite low…People laughed at
them and said, ‘scalpels do not even value as much as a barber’s scissors’. Do you think
this is fair?"

As well as receiving their hospital bonus for prescribing, doctors also receive kickbacks from pharmaceutical companies, based on their level of prescribing. Drugs have high profits margins for pharma companies - and some of this is passed on to the prescribers.
"The profit for the pharmaceutical company is around 5-15% of the wholesale price, and 10-30% for the hospital." - pharma industry manager.
This is where it gets interesting. According to Yang, the pharma companies have promotional budgets that they disburse to hospital in the form of bribes (incentive payments/commissions) to the doctors - but more importantly to the hospital pharmacy committee. This committee, which includes the director of the pharmacy department, the vice hospital president, directors from various medical departments, and some other specialists, decides which drugs are purchased and used by the hospital.

The committee members are targeted by pharma industry representatives, who develop personal relationships with them and offer bribes.
"The most important thing is to know who are the key persons in the Hospital
Pharmaceutical Committee …targeting the right persons is the key. The second step is to
persuade the persons to speak for you at the meeting. We offer money…It is possible that
the first time they will reject you… in the end, they will accept your money ... Some
medicines need a lot of money to get listed in a hospital, especially for Chinese medicines."
Once a hospital has agreed to stock the drug, the pharma company must then target individual doctors with offers of commissions to prescribe their particular drug. Doctors may be offered a commission of 15-20% of the drug price. This encourages doctors to prescribe the most expensive drugs and for long periods. Sometimes doctors are paid indirectly, with the drug company paying them 'lecture fees' or 'travel fees'. "
"Sometimes, a doctor does not need to give a lecture. We issue a receipt under a title of ‘fees or academic lectures’. We will transfer the money to the doctor as a way to pay for drug remunerations. This way, everything is legal."
This was seen in the major crackdown on GlaxoSmithKline in Shanghai, which resulted in a hefty fine. But according to Yang, such payments have been standard practice for all drug companies.
" Drug remunerations are paid monthly based on how much the doctor prescribes. In Shanghai, a doctor work in outpatient clinics in a Class III hospital can earn up to 50,000RMB a month from pharmaceutical companies," said one pharmaceutical representative.
As in other countries, pharmaceutical reps develop close and friendly relations with doctors in order for them to prescribe their drugs. They take the out for dinner and may also support them in informal ways such as by giving them lifts.

Because of the commissions, doctors are encouraged to look at the price of the drug first and foremost, rather than whether it is the most appropriate drug - or the best value for the patient. Doctors are also encouraged to prescribe worthless 'tonics', which have a generous markup and which they know they can offer to patients without fear of too many side effects:
"The most widely used medicine in my company is X. It could be used on a lot of diseases, for recovery. Drug remuneration is around 20% of the retail price…You may not need it, but anyway, it will not kill you (so doctors will prescribe it)…"
In the concluding remarks, Yang Wei notes that the Chinese government is now trying to move away from the commission system for drugs in hospitals. It has encouraged 'zero markup' policies for hospital pharmacies and has also introduced lowest price tenders to ensure that inexpensive drugs get first priority. However, Yang notes that faced with the need to generate revenue, hospitals simply sidestep these reforms by creative accounting and supply deals in collusion with the pharma companies. And when barred from generating income from drug sales, hospital simply switch to profiteering from other services such as medical devices such as cardiac stents (Y2000 each) - or offering unnecessary checkups and tests.
"If pharmaceutical revenues are cut down, then we have to increase other fees or increase the use of other services, such as the use of various diagnostic procedures. This is what is
happening now, and the healthcare costs will continue increase and remain high ... In order to follow the policy and to keep the profit of the hospital, hospitals may promote use of high-tech diagnostic procedures, special wards and other methods to increase non-pharmaceutical expense…"
Yang concludes that the problem of overprescribing and/or overservicing will remain until the Chinese central government and the Ministry of Health solves the problem of adequate resourcing for hospitals. Local governments have no incentive to enforce curbs on their local hospital revenue - and the central government has little enforcement clout at the local government level.

Link to full article: Health Economics, Policy and Law

Tuesday, 23 February 2016

China's Top 10 Lei Feng medics (the 2016 Noble Prize for Doctors Working While Conspicuously Sick)

About two years ago China's health minister Li Bin had a problem. The masses were not happy with her privatisation reforms of China's healthcare system. Prices of medical treatment were going up, service levels were way down and there was a widespread and justified suspicion among the public that they were being ripped off by a corrupt and dysfunctional health system centred around the state-owned monopoly of for profit 'public' hospitals. It was hard to see a doctor, expensive to see a doctor and the treatment was brief, perfunctory and often inappropriate.  Patients were being prescribed expensive drugs they didn't need, just so the doctor and the hospital could generate more income.

Unable to vent their frustration on the Party, the public started attacking healthcare staff. Doctors and nurses were abused for being on the take, and sometimes assaulted - even stabbed and killed. Hospitals were disrupted by family members unhappy with their treatment -  doctors were blamed - sometime even held hostage. There was a widespread feeling that doctors were useless, arrogant and often on the take in he form of commissions and hongbao (red envelopes).

So what did health minister Li Bin do? As usual in China, "moulding public opinion" (propaganda) was one of the standard methods for managing the masses. Li Bin turned to propaganda chief Liu Qibao (刘奇葆) head of the Party's 'publicity' department. His solution to restore confidence in China's healthcare system was a campaign to portray doctors as heroic, selfless martyrs, serving the people. The order was passed down through regional propaganda channels for media outlets at provincial, city and township levels to feature prominent stories of heroic doctors. "Capture the Lei Feng spirit of the heroes and angels in white coats" was the decree. 

[If you don't know, Lei Feng was a fictitious PLA soldier character invented during the 1960s, who was portrayed as selfless, virtuous and totally devoted to serving the Party through helping others. Lei Feng was the Communist version of a saint.]

Each TV & radio station, newspaper and magazine was given a quota of at least one 'Lei Feng doctor' story every quarter. Unable to find many real-life saintly doctors,  editors and reporters racked their brains to come up with ideas. One of them in Yunnan came up with the idea of a selfless doctor turning up for work even when they were sick. In China sickness and tiredness are taken very seriously, with constant exhortations from family and friends to rest, take it easy and eat some medicine/wrap up warm when sick. So the image of a doctor ignoring all this folksy advice and going to work was a very powerful one. To ram home the message, the doctor was portrayed as being rigged up with an intravenous infusion via a cannula in the arm. Again in image-conscious China this is the bog standard visual standard that says "I am sick".

The article about the selfless and noble doctor working despite being sick was very successful and generated a lot of sympathy via social media.  And as with most successful ventures in China, it quickly spawned  imitators. Other media outlets began to run their own copycat versions of the "Sick Doctor Still Working" story and they have become a regular weekly feature of the Chinese media since since 2014. And in a case of life imitates art, it has now become fashionable for medical staff to do self portraits of themselves working while sick.

And so to celebrate this ongoing selfless doctor I'm-Sick-But-Still-Turning-Up-For-Work schtick (Dai Bing Shang Ban in Chinese), China Medical News present this year's inaugural China's Top 10 Lei Feng Medics awards.

Number 10: Dr Feng Wei, Shaanxi

Our first entrant is a Dr Feng, 42, a neurologist from Shaanxi. He was photographed working with a drip stuck in his arm. His patients were reported as saying he had a wonderful, dedicated attitude to his work and would not go home despite having a nasty cough. Get well soon Dr Feng! (but you lose marks because a drip is now so unoriginal).

Number 9: Beijing Children's Hospital

Not to be outdone by provincial upstarts, Beijing's propaganda team felt that just having one doctor with an infusion at work was not enough. The capital had to do better so they found a pair of female doctors on duty - one with 'phlebitis' requiring IV antibiotics, while the other had asthma that required constant use of a nebuliser. Never mind that anyone needing that much inhaled drug likely has very poorly controlled asthma, setting a poor example of asthma management. Tut tut. Amateurs.

Number 8: Unnamed doctor, Suzhou Second Affiliate Hospital

Not sick, exactly. but dead on his feet. This unknown cardiac surgeon assistant was photographed by a journalist while napping next to a patient. in the ICU. According to the blurb the young doc was so exhausted after doing several hours of surgery that he had to catch up with some sleep while on the job. In some countries this would be condemned as working unsafe excessive hours. In China it is lauded as being a noble example of overwork.

Number 7:  Dr Wu Xiaoqing, Guilin

Infections and fatigue are for wimps. Real doctors go to work with broken bones. Just ask Dr Wu, an orthopaedic surgeon, from the beautiful city of Guilin. He was pictured hobbling round the Guilin Medical University Hospital on crutches, having allegedly fractured his ankle in a motorbike accident. The patients thought his presence at the hospital was a reassuring sign of devotion. We think it is a sign of stupidity - especially from an orthopod, showing a bad example to his patients.

Number 6: Dr Li Ming, Jiangsu

 Never mind crutches, Dr Li of Jiangsu showed that the smart doctor with mobility problems gets some wheels. She turned up for work, allegedly, at the stomatology  department of the Xuzhou No 1 Hospital. Bonus points for the mask Dr Li - you don't want to get sick from patients, it might mean you have to take time off work!

Number 5: Dr Zhao Hongyan, Tianjin 

When it comes to mobility, the military always do things better. When her injured leg meant she could not walk to work,  Dr Zhao Hongyan  of the  Armed Police Force Logistics College Affiliated Hospital in Tianjin spurned a wheelchair in favour of the electric variety. Working while sick and also promoting the Four Modernisations!Top marks for efficiency Dr Zhao, but a fail for your blinged up wheelchair lacking the pity factor for eliciting sympathy from the masses.

Number 4: Nurse Chen, Harbin

 This one isn't a doctor, but the so called "Angel of the Hospital" was celebrated in the media for her selfless attitude to healthcare work when she worked despite having a slipped spinal disc. Allegedly in severe pain, Nurse Chen nevertheless was determined to persevere with the paperwork, so she lay down on some chairs. Thanks for taking the strain of your colleagues - as well as your back -  Hero Nurse Chen.

Number 3: Dr Zhang Hong, Hubei

OK pregnancy is not a sickness, but ultrasonographer Dr Zhang Hong of Wuhan is portrayed as the 'Beautiful Doctor and Beautiful Mother' in the local media for working right up until the term of her pregnancy. Dr Zhang said she felt tired and dizzy but did not want to let down her colleagues or her patients. Not sure if this is genuine or posed.

Number 2. Dr Li Zhengyong, Sichuan

Most of our nominees so far have had temporary sickness that should have prevented them from working. Dr Li Zhengyong of Jiulong, Sichuan has a permanent disability from losing a leg after being hit by a truck  decade ago. Despite having only one leg the 35 year old  dedicates himself to working in the village. It may be propaganda but you've got to admire him.

Number 1: Li Juhong, Hechuan

And the winner is .... drumroll ... the ultimate prize for working while sick must go to this noble lady doctor of Hechuan village near Chongqing. An amputee since the age of four, Dr Li worked her way though rural medical collage to become a township medic serving about 1000 patients. Yes, it's a propaganda piece, but Dr Li deserves all the kudos  - and the Golden Lei Feng Award - for her super service.

Now, who's got the nerve to be nasty to doctors?

Meanwhile, here's a few thoughts for the Health Minister and Propaganda Minister to mull over:

* If you're sick enough to need an IV drip in your arm, perhaps you are not well enough to perform your medical duties to a safe level. You are putting patients at risk.

* If you have an infection that requires antibiotics, it must be serious. Why are you putting at risk vulnerable patients and colleagues through transmitting this infection in the hospital environment?

* IV antibiotics are not appropriate for routine infections. It's bad medicine. What kind of example are you setting to your patients (and to junior colleagues)?

* Would you advise your patients to continue working while seriously ill? No, because it delays recovery. So don't lead by bad example.

* Doctor's health is important. Doctors need to be healthy. By showing up for work while sick you are normalising and encouraging unhealthy behaviour. You may be putting pressure on other staff to do the same.

* Patients aren't stupid. They know that seriously ill people should not be working. By making an ostentatious show of working while sick, you are eroding trust in the medical profession and the judgement of doctors.

Sunday, 21 February 2016

Why Beijing's war on hospital ticket scalpers is doomed to fail: top cardiologist says jail sentences won't fix supply & demand problem

This week a Beijing court sentenced 15 hospital ticket scalpers to prison sentences varying from 19 months to two years in jail. It's all part of a very public crackdown on the practice of 'entrepreneurs' buying up the hospital clinic reservation numbers (guahao, ) that are needed to gain access to see a doctor. Typically, these hospital tickets cost 20 yuan at the front desk but are bought up and sold for ten or more times their face value by scalpers (piao fanzi, 票贩子) who operate in gangs around the foyers of public hospitals.

In theory, China's hospital clinics operate on a first come, first served basis. Whoever is prepared to queue up early at the hospital ticket window in the morning gets the tickets. In practice, the scalper gangs either send their agents to stand in line and book an appointment - or they have inside connections with hospital staff to procure the tickets through the back door. The corrupt practice has been going on for years, but made headlines in January when a video emerged showing a young rural migrant woman ranting about the scalpers at a Beijing obstetrics hospital. The video went viral on China's social media channels and there was soon public pressure for 'something to be done'.

As in the past, the hospitals and the Beijing health department announced yet another "get tough" campaign on scalpers. They sent in the PSB to round up the usual suspects. They also issued a series of "Five Musts" measures that included real name registration procedures and an end to collusion between hospital staff and scalpers. And as usual, an example has been made of a few offenders in the media. The Party has listened to the masses and taken action. Never mind that the 15 offenders sent to jail weren't actually scalpers, but fraudsters. They had hired hospital rooms in which they used bogus doctors to swindle unsuspecting out-of-towners into jumping the queue and paying for dodgy TCM treatments.

But even if the authorities had enacted a serious and enduring action against hospital ticket scalpers, it still would not make any difference, according to one leading cardiologist.

Professor Yang Qing, has worked at the cardiology department at the Sichuan University Huaxi Hospital for 20 years. He says the problem is not due to the scalpers, who are only the symptoms of a monopolistic system. Professor Yang says it is important also not to blame doctors, who are also constrained by the system.

According to Professor Yang, every day his hospital cardiology clinic in Chengdu is besieged by patients from far and wide, seeking a consultation. Patients come not only from Chengdu, but also from across the province and even from overseas. A typical clinic has 20 allocated slots to see patients with an average consult duration of 6 minutes - but most will actually fit in 30 patients by running over time. Every day at the front desk he is mobbed by people saying: "Professor Yang can you add an extra place for me?" Some are very deserving patients who have traveled a long distance to see him - even renting rooms near the hospital. Others are former patients who want continuity of care and to be followed up by the same treating doctor. And there are also 'insiders' - acquaintances, connections and people who work in the hospital who seek an appointment with him.

Professor Yang says the demand for 'tickets' is inexhaustible and he only has a finite amount of time in a working day. On a typical day he works right through an after noon clinic without a break even to go to the bathroom. He is supposed to finish at 5pm, but usually does not actually finish until at least 6pm. If there is a chance he will add a few extra places, but he says he feels bad for not being able to accept all the requests. And his colleagues all feel the same way. They are not heartless, but they have other responsibilities and things to do - not to mention family life. Professor Yang says that in addition to attending to patients in the outpatient clinic he must also do surgery, supervise junior staff, take part in research and write reports. He must attend medical conferences and teach students.

Professor Yang says that the demand for hospital tickets is high, but the price is low and does not reflect the 'economic value' of the doctors' skill and experience. The scalpers are simply selling the doctor's appointment at a price the market is prepared to pay, he says. And the 'profit' is going to criminal gangs instead of to the hospitals.

Professor Yang says that what the scalpers do is an unsatisfactory and unfair situation, but he believes it is inevitable under a monopoly system. It would be unrealistic to expect them to be stamped out - and even if all the ticket scalpers were removed there would still be an imbalance between supply and demand of medical appointments, he says.

"When a resource is scarce, and when everyone wants to have this resource, the authorities' fight against ticket brokers is meaningless," he says.

Professor Yang says that in theory a system that guarantees low prices is good because it makes treatment affordable for everyone. However, in practice he says low prices enforced within a monopoly lead to low quality care and also to the 'detestable' practice of scalping.
Professor Yang's solution is a free market one - free up the doctors to set their own prices and let them manage their own patients. In this way, there will be competition between doctors that will keep prices low and affordable while raising levels of service and quality, he believes.

[Editor's note: Given that they have been given prominent place in the state media, Professor Yang's pro-market comments are presumably endorsed by the government and China's minister for health. It's notable that the learned professor suggests a new model based on the US free market healthcare system, and makes no mention of other more successful models such as the gatekeeper' system of Britain's NHS. 

The kind of problems that Professor Yang describes do not occur in the UK  because that country (like many others) has an efficient primary care gatekeeper system that ensure that patients do not go straight to hospital. To see a hospital specialist, patients in countries such as the UK and Australia must first go to see a community-based general practitioner, who decides if and where they should be referred. This means that patients with minor illness and chronic disease can be managed in the community' rather than clogging up the overloaded hospital system. It also means that patients are sent to the most appropriate specialist. 

Of course the system isn't perfect because financial restraints mean that public hospital patients often have to wait months for an appointment to see the doctor. In countries such as Australia, patients can jump this queue if they have private health insurance (but they still need a GP referral) But if any patient needs urgent care, they can receive it. 

Interestingly, China is pursuing both these options. It is loosening the monopoly of public (actually state-owned for-profit monopoly) hospitals. China is also moving towards a community/family doctor system. However the progress is glacial because of the entrenched financial interests of local governments [and managers] in their local hospital monopoly. So is the solution to hospital scalpers a crackdown, free-market healthcare or a gatekeeper system? You decide ...]

Monday, 15 February 2016

China's pediatrician shortage to worsen with two child policy


In Guilin's main children's hospital this New Year there were only three doctors on call to cover more than 30 beds for children - and a long waiting list - around the clock. Last year there were seven doctors but four have resigned.

Doctors at the hospital say there is a vicious circle - as more paediatricians resign, the pressure on the remaining doctors gets worse, and the speciality becomes even less attractive to other medical graduates. Speaking to local media, paediatricians say there problem is an increasing one for the whole of China. Paediatrics is an unpopular branch of medicine that finds few takers.

One of the reasons is the low income compared to other branches of medicine - paediatricians don't get the opportunity to make extra bonuses or commissions from surgical operations, prescribing drugs or providing medical devices.

Secondly there is the intolerable pressure from pushy parents of Little Emperors. Children with only minor illness are brought in by neurotic parents who demand attention and excessive or inappropriate treatment for their child. Doctors working with children say their parents and grandparents can be obnoxious - expecting immediate treatment and instant miracles for their spoiled child. This often leads to abuse, disputes, complaints and legal action between doctors and families.

Thirdly, paediatricians also struggle with what they call the "dumb patient" problem - unlike adults, children cannot explain their problem well, and therefore doctors need much greater clinical skills to be able to diagnose their illness.

The low income, high pressure and lack of respect means that paediatricians get little satisfaction from their work. Not surprisingly, many vote with their feet and leave.

The lack of child specialists means that the remaining doctors face 12 hour shifts every day - and have to work as many as 10 night shifts a month. Paediatricians are already exhausted and demoralised  - and they expect the situation to become even worse as two child regulations come into effect in 2016.

Thursday, 11 February 2016

Hospital gangster siege reveals the murky side of China's healthcare management

The bizarre 22-day occupation by mobsters of a hospital in Zhengzhou, Henan, is a revealing example of the murky finances and power arrangements behind China's hospitals. 

In late December almost 100 unidentified men invaded the Zhengzhou Meixin Chinese Medicine Hospital and disrupted its operations for more than three weeks. According to Chinese media, the men  - many wearing masks - obstructed the lobby, harrassed medical staff, put up banners and drove patients away. The hospital was thus put under siege by local thugs who stayed in the building playing cards and intimidating anyone who entered.

However, this was not the result of a medical dispute by aggrieved family members of a sick patient, but an extortion attempt to try recoup huge unpaid debts owed by the hospital manager, Wang Guangyu. According to Chinese media reports, the mob had been sent in to force Wang to make good on 17 million RMB funds that he owed to a distant relative, Li Jing. Her husband had previously invested more than 40 million in the hospital via Wang Guanyu, but after the husband died last year, the funds were not repaid in full. After several rebuffs, Li Jing called in the rest of her family to put some muscle on Wang.

In any other country a dispute like this would be settled by the police and the civil courts. However in Henan, amazingly, the ringleader of the occupation gang, Guo Zhiyang, was himself the leader of the local justice department and a former senior policeman.

For someone who is supposed to be upholding the rule of law, Gui Zhiyong appears to be a pretty lawless and criminal character. During his occupation of the hospital staff were threatened by men bearing knives and poles. One pregnant member of staff was so terrorised that she went into premature labour.

The incident ended on 9 Feb after provincial media became interested. When outside journalists first visited the hospital they were rebuffed, but were able to make some reports and take pictures. When this made the news beyond Zhengzhou, the occupiers slipped away, leaving the hospital deserted.

Guo Zhiyong could not be found but he issued statements saying he had been trying in a reasonable and lawful manner to handle personal matters with family. He accused the media of slander through their portrayal of him as a gangster and said he would take appropriate action to defend his reputation.

The whole saga may be an instructive lesson for any foreign companies contemplating running a hospital in China!

[Note: this incident is also reported by a "Gloria Chan" of the SCMP . However, the article so sanitised and anodyne as to be incomprehensible. Presumably this is the SCMP's way of trying to please the Chinese government by not washing China's dirty linen in public.]

Sunday, 7 February 2016

Why are China's doctors dropping dead?

 In a single week in 2013, four doctors died suddenly of cardiac arrest. Meanwhile in the last two years it has been reported that fifteen anesthetists in their thirties and forties had sudden cardiac deaths. There have even been premature deaths among distinguished surgeons. What's going on?

According to Dr Huang Weimin, an orthopaedic surgeon at the General Hospital of Jinan Military Region in Shandong, doctors are simply being worked to death. It's the Chinese medical equivalent of karoshi (death from overwork). The Chinese and Japanese characters are the same: "过劳死" (Guolaosi).

Writing in the International Journal of Cardiology this month, Dr Huang says there are four main factors that are driving Chinese doctors to an early grave:

1. Excessive hours and work intensity. Doctors work up to 12 hours a day and in general at least 50 hours a week.

2. Extra non-clinical duties. Doctors are required to publish a quota of scientific articles every year to remain qualified and to be eligible for promotion. This requires research, finding funds, and doing the necessary paperwork for publication. All this work must be carried out in addition to their general clinical work, often in their own time.

3. Doctors must attend many meeting and medical conferences and also have a heavy teaching and supervision burden.

4. The excessive workload and lack of time contributes to a deteriorating doctor-patient relationship, which results in more pressure on doctors and also doctor-patient disputes, litigation against doctors and violence against doctors.

Dr Huang says that all these factors have been highlighted by the doctors' trade union, the Chinese Medical Doctor Association (CMDA). In May 2015 the CMDA issued a “White Paper on the Practice of Chinese Doctors” which called for an easing of pressure on doctors.

It noted that more pressure on doctors can be expected with China's ageing population, the increase in prosperity and consumer expectations, and the widening of medical insurance coverage.

"The growing rates of sudden death indicate that doctors in China are already exhausted and they need alleviation of the heavy burdens. It is high time to concern the health of doctors," writes Dr Huang.

"On one hand, the government should optimize the allocation of medical resources, improve medical evaluation systems, and legislate to protect the health of medical staffs. On the other hand, the society should give more understanding to doctors and create a favorable working conditions."

Tuesday, 2 February 2016

Chinese media cranks up "Heroic, Selfless Doctor" propaganda

For the last year there has been a steady drip-drip of doctor-as-hero stories appearing in the Chinese media. A typical (and recurrent) one is the story of the sick doctor who keeps on working despite being ill enough to require an infusion line stuck in his or her arm. This is presumably intended show show how dedicated the doctor is in the spirit of that selfless icon Lei Feng.

In reality these stories make the doctor and the health service look foolish and backward. No professional doctor would turn up at the hospital if they have an infectious disease. And no self respecting doctor would believe that an infusion is the right treatment for an ambulant patient. If you're sick enough to require IV antibiotics then your place is in a hospital bed, not the doctor's seat.

The fact that these stories appear on a regular basis in the Chinese media suggests that there is some ongoing propaganda edict from on high to publicise selfless healthcare staff.

Until now, these doctor-as-Lei-Feng stories have just been an occasional eyebrow-raising oddity. However in the last month or so there have been more and more such stories appearing in the media. Last week there was a story of a doctor who was so busy that his son resorted to booking an appointment as a patient so that he could get to see his father. In a family-focused society such as China this 'heart-rending' story was no doubt intended to show how overworked and noble the Chinese doctor is.

This week the selfless medic story of the moment is one concerning Zhejiang doctors who have reportedly been lending money to poor patients so that they can pay for their medical treatment.

According to the local media, a female doctor Yang Yonghong, chief physician at Zhejiang Taizhou Municipal Hospital of Infectious Diseases lent 500 yuan to a patient who said he could not afford to pay for the antibiotics he had been prescribed. Dr Yang insisted that the man take the money to pay for an IV infusion for his sepsis. According to Dr Yang, the man had a life threatening infection that needed immediate treatment. When he wavered about paying, Dr Yang handed over the money and said he could repay her later.

The man reportedly left and did not return for his infusion. But Dr Yang said it was better to offer money and lose it than to risk a patient dying. Fortunately for this doctor the story had a happy ending when the patient returned two days later to repay her. He said he had sought treatment at a local clinic because it was too late to return to the hospital. The patient then allegedly made a full recovery.

Dr Yang has since become a local hero on social media for her generous and selfless action - especially as she was very self deprecating, saying it was nothing, and that many doctors performed similar acts of generosity every day.

"I often ask patients about their economic circumstances and if they are not rich I try to prescribe cheaper drugs and treatment. Last year I lent several hundred yuan to patients who could not afford treatment - I did not hear back and I hope they are well," she is quoted as saying.

The whole sounds very fishy and too good to be true. Is this Xi Jinping's way of sugar coating the medical reforms that will require patients to pay higher fees for medical care?