Globally, healthcare industries are making slow but steady progress in gaining the trust of the public, even while the general trust in business, government, NGOs and the media is in an overall decline (Kym, 2017).
Not in China. If you ask a random person in the Mainland about the healthcare services, the first thing coming to their mind will most probably be distrust.
- THE SITUATION IN CHINA -
In 2015, ‘Yῑ Nào’ (医闹) was the hottest online keyword associated with healthcare on Chinese forums (DXY, 2016). This term refers to either the violence committed by patients or their relatives to seek compensation when feeling unsatisfied with healthcare service, or to ‘agents’ who use violence to extort such compensation for those who hire them.
Violence in healthcare first emerged as an issue in China in the early 1980’s, and entered the policy agenda in 1986. Since then several related policies have been released by the Ministry of Health, the Public Security Bureau, and by the Ministry of Justice (Yao et al., 2017). However, the increased averseness did little to curtail the explosive swell of the incidence rate. The number of assaults has kept rising and the situation has become worse than ever before. Chinese hospitals became “fraught with tension” (Lancet, 2012). The quick erosion of trust has led to the emergence of a ‘twisted mindset’ towards healthcare service in the society (Table 1; Chuang Xin Yi Xue Wang, 2017). The worsening patient–physician mistrust was identified even by Chinese government leaders as a major problem (Lancet, 2014).
- VIOLANCE AND HEALTHCARE IN CHINESE MEDIA -
Violence in healthcare has gained the Chinese media’s attention since 2002. The number of news reports covering the topic has gone through a dramatic increase since 2011 (Figure 1, Yao et al. 2017).
Most of the media attention has been focused on violence reported from Guangdong, Sichuan, Zhejiang and Jiangsu provinces – regions with medical resources above the Chinese average (Table 2). This finding is consistent with the other earlier similar research (Figure 2; DXY, 2014).
Intriguingly, violence occurs mostly in hospitals accredited as Tertiary A level (the highest level in hospital accreditation in China) and comparatively well equipped and well staffed Emergency Departments. Victims are mostly doctors who were directly involved in treating the patient linked to the violent behavior. (Table 3)
Those who conducted the violence were mostly local residents with no history of mental illness and the aggressive behavior was dominantly not premeditated but under a spur-of-the-moment choice. In most of the cases the assaults were not linked to patient death, no surgery was conducted beforehand and no third party was involved. (Table 4)
The incidents can be divided into three levels: disrupting the order of the healthcare institution, such as displaying a dead body in front of the hospital as a protest; causing injury to members of the healthcare staff; and lastly, murder. Of these three types, the second one was found to be the most common one. Interestingly, patient death, pre-planned acts and collective actions are less likely to be related to server incidents. It is also worth pointing out that in nearly half of the cases (42.3%) the future offenders have ever tried to solve the problem via legal ways.
- WORKPLACE VIOLENCE AS A PUBLIC HEALTH ISSUE -
Violence was recognized as a cause for concern for public health roughly 40 years ago in the US – in a time of retreating infectious diseases and increasing numbers of homicides (Dahlberg, 2009).
After several US postal employees were killed by present or former coworkers in separate shootings in 1983，US media started to report more frequently on incidents happening at workplaces. This led to workplace violence being recognized as a public matter by the Federal Bureau of Investigation (FBI, 2003). By the Bureau’s classification, cases of workplace violence fall into one of four broad categories. Violence against healthcare workers belongs to the 2nd type of workplace violence (Table 5; FBI, 2003). Indeed, it is listed as a special case by the FBI as “Employees experiencing the largest number of Type 2 assaults are those of healthcare occupations…” (FBI, 2003)
- WHY CHINA? -
1. SCARCITY OF RESOURCES / SOCIAL PRESTIGE ?
The basic logic of economics states that if a resource is scarce its value will increase. If people start killing doctors, does it mean that they think doctors are not valuable? Is China so rich in doctors and nurses that people just don’t treasure them? Not quite so. Ranking 81 out 175 countries, China is right at the middle of the range. (CIA World Factbook). Is perceived value more important than absolute scarcity? Is it Chinese people’s perception that healthcare workers are less valuable than, say, teachers?
2. MARKETIZATION OF HEALTHCARE ?
Zhang & Feng’s study (2017) reveals that since 1992, the start of maketization of healthcare in china, the number of medical dispute per year has increased from 232 in 1991 to 1400 in 1998. 2003 saw 5000 medical disputes reported just in Beijing (Figure 3).
1992 was the year when the Chinese Ministry of Health announced a deep reform of the public health system. That year the Ministry started to encourage hospitals to develop profit-oriented services while reducing the amount of compensation provided by the government. Soon, sceptical voices started arising from the society about the hospitals, viewing them as focusing too much on profits instead of healing.
Since then the public’s perception of injustice has led to mistrust between patient and physician: After the maketization reform, the government’s financial support to hospitals decreased to 15% of the overall budget, leading to low pay among healthcare workers (Tucker et al. 2015). Furthermore, as the hospitals need to provide for-profit services to maintain their operation, the system brings perverse incentives to healthcare system. For example, to offer unnecessary examinations to patients since these services bring considerable profit.
3. MEDICAL EDUCATION ?
Some researchers criticise the lack of training medical students receive in empathy and care giving, while the students’ selection itself is based only on tests rather than on a sense of vocation, aptitude or attitude (Tucker et al. 2015; Lancet, 2014).
The structure of Chinese medical education may actually contribute to the low social value attached to healthcare workers (Yin, 2016). In the US medical associations have been lobbying the government since the 1910’s to cut down the number of medical education institutions by closing down those with poor performance. This has contributed to the improvement of the healthcare workers’ social status. The resulting high salaries, on the other hand, attract top students. Meanwhile, it is said that the Chinese medical education system is the most confusing one in the world (Wu et al., 2007). There are several different medical degrees from actual doctors who study clinical medicine to people studying sports, public health, healthcare management etc.
What’s more, the selection criteria for Chinese healthcare practitioners are not based on whether the applicant had obtained a medical degree but on ‘medical study experience’. In other words, if you completed your courses but didn’t get a degree, but you have certain work experience, you are qualified to take the admission test and if you pass, you may become a practitioner.
4. FEE FOR SERVICE & THE UNDERDEVELOPED PRIMARY HEALTHCARE SYSTEM ?
Unlike countries with General Practitioner (GP) referral system in healthcare, patients in China can choose the providers of healthcare services freely. For example, people can request hospital services without a GP’s referral. People prefer to go to higher level hospitals (Tertiary A level) even with a simple cold as they trust them more than those of lower level. This is because that there is a lack of standardized healthcare practice and medical education in China. In the US, for instance, it makes no difference to go to community hospital or the famous Harvard University hospital because the standard of service is all the same. But in China, the development of primary healthcare system is challenged by the strict administration system, such as the technology admission system, national essential drug system, the hospital accreditation system etc (Liao, 2016). Due to the lack of healthcare resources and low level of institution standard, community hospitals find it hard to apply for more senior technology or to have more categories of medicine (Liao, 2016).
Consequently, a vicious loop arises in which the primary healthcare system cannot attract patients and keep healthcare workers, while tertiary hospitals are overwhelmed by patients. With a combination of such high expectations, over-crowed environment, long waiting times and short consulting times, it is hardly surprising that higher level hospitals have become the most likely place for violence to occur (Table 2).
- NOT JUST CHINA -
As mentioned before, in the US, violence against healthcare workers has caught attentions from government and the whole society. American scholars, for example, have suggested the creation of a blacklist for patients who conducted violence in healthcare institutions (Phillips, 2016).
Several other countries around the world are in the process of tackling similar issues. For example, in Spain April 20 is the National Day Against Aggression in Health-Care Facilities. It was created as a response to the murder of a resident family doctor by a patient in 2009 (Marlasca M. M. O., 2014). Even more telling is the fact that a researcher from noted believed that the situation in India is worse than it is in China. (Bawaskar H.S. 2014)
Due to the increasing rates of violence in healthcare institutions, Korea has recently implemented a revised law on healthcare with a specific clause on violence newly included (Huanqiu News, 2016). According to the new Korean rules, offenders may be sentenced to 5 years in prison (Huanqiu News, 2016).
- SUMMARY -
This brief introduction to workplace violence in healthcare settings focused on China’s case. While the issue is not unique to China, by exploring the Chinese case we might arrive at important conclusions.
We invite all of you all to share your opinions:
First of all, how to repair the damaged trust between the demand side and the supply side of healthcare service in China?
In terms of some deeper social determinants of the distrust, detailed bullet points are:
The failure of the market mechanism in the healthcare industry: Why doesn’t the scarcity of human resources raise the prestige of healthcare workers?
Maketization of healthcare: how to improve efficiency while also protecting quality? Should there be no for-profit elements in the public healthcare system? With a limited national budget, should the government invest more money on the demand side or on the supply side, or how to balance both sides?
Medical education: should China learn from the US’s experience – by cutting the number of medical students - so that the value of healthcare workforce can be increased due to the reduction of supply?
Fee for service and the primary healthcare system: how to reverse the Chinese public’s over-heated favor for tertiary hospitals into an incentive of building a strong primary healthcare system?
REFERENCE
Bawaskar H.S. (2014) Violence against doctors in India. Lancet. September 13. Vol 384.
CIA. THE WORLD FACTBOOK – Physician Density.https://www.cia.gov/library/publications/the-world-factbook/fields/2226.html
Chuang Xin Yi Xue Wang(创新医学网) (2017) https://mp.weixin.qq.com/s/BuZZT7JqFYi2_kUGVoY3BQ
Dahlberg L.L. & Mercy J.A. (2009) History of violence as a public health issue. AMA Virtual Mentor. February. Volume 11, No. 2: 167-172.
DXY(丁香园调查派) (2014). 医疗场所暴力事件回顾：伤医频发, 广东最伤.http://vote.dxy.cn/report/dxy/id/69182
DXY(丁香园调查派) (2016) 2015年医疗界年度热词出炉.http://vote.dxy.cn/report/dxy/id/480866
Federal Bureau of Investigation(FBI) (2003) WORKPLACE VIOLENCE: ISSUES IN RESPONSE. National Center for the Analysis of Violent Crime FBI Academy, Quantico, Virginia
Huanqiu News (环球时报) (2016) 韩国新医疗法开始实施 对医护人员施暴最高可判5年. http://world.huanqiu.com/exclusive/2016-06/9030954.html?nra
Kym White (2017) Trust in Healthcare: Making Progress. Edelman. http://www.edelman.com/post/trust-healthcare-making-progress/
Lancet (2012) Ending violence against doctors in China. Lancet Vol 379:1764
Lancet (2014) Violence against doctors: Why China? Why now? What next? Lancet Vol 383:1013.
Liao XinBo (2016) 家庭医生签约制之中国困境. http://blog.sina.com.cn/s/blog_4940b3f60102wgsc.html
Marlasca M. M. O. (2014) Tackling violence against health-care workers in Spain. Lancet Vol 384 September 13
Phillips, J. P. (2016). Workplace violence against health care workers in the United States. New England Journal of Medicine. 375(7), 14.
Tucker JD, Cheng Y, Wong B, et al.(2015) Patient– physician mistrust and violence against physicians in Guangdong Province, China: a qualitative study. BMJ Open.5:e008221. doi:10.1136/bmjopen-2015- 008221
Wu LJ, Peng XX, Wang W(2007). 医学学位在医师职业生涯中的作用——中国与英国的比较研究. 学位与研究生教育(10), 65-68.
Yao Ze-lin, Zhao Hao-yue & Lu Si-jia (2017). Right-protection by Violence in Healthcare Service and Its Governance:Based on Content Analysis of News Reports from 2002 to 2015. Social construction. 4(1).49-63.
Yin Jun (2016) Comparison of academic degree and schooling length of clinical medicine between China and foreign countries
Zhang Rui & Feng Lei (2017) A review of medical violence management policy change based on the perspective of punctuated equilibrium theory. Chinese Journal of Health Policy.10(1):14-20
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