《柳叶刀》：威胁下生存的中国医生

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61315-3/fulltext

8月18日至21日在深圳召开了世界抗癌大会。卫生部部长陈竺在开幕式致辞中介绍了中国当前医药卫生体制改革。体制改革也是这次会议的主题之一。尽管大量国际医疗卫生政策的制定者以及医生主导讨论了体制改革涉及的框架和法规，但是很少听到来自中国地方医生的声音。

许多大会中国代表更关注涉及病人和疾病的专题报告，而不涉及体制改革的全会报告。自身安全是中国医生最为关注的问题。中国医生经常成为医疗纠纷涉及的暴力事件中牺牲者。今年6月，山东省一名医生和一名护士被一名13年前因肝癌死亡的患者的儿子刺死。另一起案件是一名福建儿科医生为了躲避自己经治的死亡新生儿的亲属围攻，从15楼破窗跳楼逃走。因此对于今年7月份沈阳27家医院聘请警-察当副院长的举措也就不足为怪了。当医院被医疗暴力包围的时候，医生成为了危险职业。导致医患关系紧张的一个主要原因是许多中国患者认为医生和医院对自己做了不必要的检查，处置和治疗，从而导致病人医疗费用增加。此外，医生违规收红包加剧了医疗纠纷和暴力事件的发生。很多病人责备医生缺乏爱心和专业技能，从而直接导致了患者自身病情的恶化。医生是一个美好的职业，有着美好的比喻。例如在古代，许多中国人梦想成为在宰相或者成为良医，在现代医护人员被称为白衣天使。

为什么中国医生的现状变得如此岌岌可危？毫无疑问，中国的媒体扮演了重要角色，他们加剧了当今医患关系的紧张。报刊，电视以及互联网上有大量关于健康专家以及医生如何欺骗病人的报道。几周前，广东省有影响力的《南方都市报》不真实的报道了一名中年妇女生小孩后，因做痔疮手术导致肛门被缝。2009年11月，中国官方媒体CC-TV报道北大医学院医学生非法进行医疗实践，外科手术后导致病人死亡。相反，医院和卫生部声明在有行医执照的医生监督下，医学生对患者进行外科手术是合法的，这种不实报道对医生和医院的声誉造成了严重影响。目前这两例报道，很难判断是因为记者缺乏医学知识导致的不实报道，还是记者和媒体的蓄意为之已哗众取宠。但是报道导致了公众的误解，最后是伤害的还是医生和患者。

在中国，大部分医院特别是超大型医院是政府办的公立医院。公立医院在1985年前享受政府财政的全额资助。经济改革后，医院接受政府的财政补贴剧减，医院需要通过自己开源节流，支撑运转。医院的主要收入来自诊断和检查。而且医院有相应的奖励政策鼓励这种过度诊断和过度治疗。为了避免不正当的利益冲突，中国政府颁布法律禁止医生从药商拿回扣。即使按照中国的标准，中国医生的工资水平偏低。许多中国医生努力在职业道德要求和满足当下中国经济迅猛发展的形势下，寻找平衡点。这种压力交织中一些来自社会和政府对医生职业的贬值，驱使很多医生转行。如果不改善医生的社会和经济地位，中国的医药卫生体制改革将不会成功。中国医生应该更多的介入到医改过程，发出自己的声音，用自己的经验和建设性意见来帮助医改制度的完善。



Chinese doctors are under threat

System change, the theme of the World Cancer Congress in Shenzhen, China, Aug 18—21, was a central message in the opening address by the Chinese Minister of Health, Chen Zhu, as he described current health-care system reforms in China. At the Congress many international health policy makers and physicians led discussions on frameworks and actions for system change, but there was little participation from local Chinese doctors.
To understand why there were so few Chinese delegates in the plenary sessions on system change compared with sessions on patients' care, one must first understand that for many Chinese doctors personal safety is of greater concern. Chinese doctors are often victims of terrible violence. In June this year, a doctor and a nurse were fatally stabbed in Shandong Province by the son of a patient who died of liver cancer 13 years ago, and a paediatrician in Fujian Province was injured after leaping out of a fifth-floor window to escape the angry relatives of a newborn baby who had died under his care. Thus, it is not surprising to see that in July police officers were invited to be the vice-presidents of 27 hospitals in Shenyang. With hospitals turned into battlegrounds, being a doctor has become a dangerous job in China.
The problem may be largely one of perception. Many Chinese patients believe that doctors and hospitals conspire to increase charges by providing unnecessary examinations, investigations, and treatments. Additionally, some doctors accept red envelopes (a monetary gift in exchange for favourable service) against the rules. Many patients blame the deterioration of their health directly on doctors, claiming that doctors lack devotion and skills. The intellectual ideals of ancient China were “either to be a good prime minister or to be an excellent doctor”, while in modern China doctors and nurses used to be worshipped as “angels in white”. How has the perception of Chinese doctors become so eroded?
The Chinese media certainly have an important role in provoking tension between doctors and patients. There is disproportionate coverage in newspapers, television, and on the internet of how health professionals have cheated patients. Just a few weeks ago the Southern Metropolis Daily (the most popular newspaper in Guangdong) falsely accused a midwife, who had treated haemorrhoids for a patient after childbirth, of stitching the patient's anus closed on purpose. In November, 2009, one of China's most authoritative media outlets, CCTV (China Central Television), reported that the renowned Peking University First Hospital was carrying out illegal medical practices by allowing medical students to do surgical procedures, and as a result a patient had died. Even though the hospital and the Ministry of Health made it clear that involving medical students in clinical procedures including surgery under the supervision of licensed doctors is legal, trust in doctors and hospitals was seriously damaged. It is hard to tell whether the misreport resulted from a lack of medical knowledge on the parts of the Southern Metropolis Daily and CCTV, or whether it was motivated by a desire for a sensational story. However, the public misunderstanding of the medical profession will surely hurt both doctors and patients in the end.
Most hospitals in China, especially the large ones such as Peking Union Medical College Hospital and Huashan Hospital of Fudan University, are run by the government. Public hospitals in China enjoyed full government funding before 1985. After economic reforms, the hospitals now receive very limited financial support from the government, with the result that hospitals must generate income to cover costs. As the main source of hospitals' income is from diagnostics and treatment, there is a financial incentive to over-investigate and over-treat. To minimise inappropriate conflicts of interest, the Chinese Government passed laws to prevent doctors receiving financial kickbacks from drug companies. Because the standard salary of a doctor is modest, even by Chinese standards, many doctors struggle to balance professional ethics and making ends meet in an economically booming China. Such pressures, coupled with a sense of feeling seriously undervalued by the government and society as a whole, drive many doctors out of medicine into other jobs.
China's health-system reforms cannot be successful without reforming the social and economic status of doctors. Chinese doctors should be involved more in shaping health policy, by giving voice to their own experiences and constructive ideas about the health system.





http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61315-3/fulltext

8月18日至21日在深圳召开了世界抗癌大会。卫生部部长陈竺在开幕式致辞中介绍了中国当前医药卫生体制改革。体制改革也是这次会议的主题之一。尽管大量国际医疗卫生政策的制定者以及医生主导讨论了体制改革涉及的框架和法规，但是很少听到来自中国地方医生的声音。

许多大会中国代表更关注涉及病人和疾病的专题报告，而不涉及体制改革的全会报告。自身安全是中国医生最为关注的问题。中国医生经常成为医疗纠纷涉及的暴力事件中牺牲者。今年6月，山东省一名医生和一名护士被一名13年前因肝癌死亡的患者的儿子刺死。另一起案件是一名福建儿科医生为了躲避自己经治的死亡新生儿的亲属围攻，从15楼破窗跳楼逃走。因此对于今年7月份沈阳27家医院聘请警-察当副院长的举措也就不足为怪了。当医院被医疗暴力包围的时候，医生成为了危险职业。导致医患关系紧张的一个主要原因是许多中国患者认为医生和医院对自己做了不必要的检查，处置和治疗，从而导致病人医疗费用增加。此外，医生违规收红包加剧了医疗纠纷和暴力事件的发生。很多病人责备医生缺乏爱心和专业技能，从而直接导致了患者自身病情的恶化。医生是一个美好的职业，有着美好的比喻。例如在古代，许多中国人梦想成为在宰相或者成为良医，在现代医护人员被称为白衣天使。

为什么中国医生的现状变得如此岌岌可危？毫无疑问，中国的媒体扮演了重要角色，他们加剧了当今医患关系的紧张。报刊，电视以及互联网上有大量关于健康专家以及医生如何欺骗病人的报道。几周前，广东省有影响力的《南方都市报》不真实的报道了一名中年妇女生小孩后，因做痔疮手术导致肛门被缝。2009年11月，中国官方媒体CC-TV报道北大医学院医学生非法进行医疗实践，外科手术后导致病人死亡。相反，医院和卫生部声明在有行医执照的医生监督下，医学生对患者进行外科手术是合法的，这种不实报道对医生和医院的声誉造成了严重影响。目前这两例报道，很难判断是因为记者缺乏医学知识导致的不实报道，还是记者和媒体的蓄意为之已哗众取宠。但是报道导致了公众的误解，最后是伤害的还是医生和患者。

在中国，大部分医院特别是超大型医院是政府办的公立医院。公立医院在1985年前享受政府财政的全额资助。经济改革后，医院接受政府的财政补贴剧减，医院需要通过自己开源节流，支撑运转。医院的主要收入来自诊断和检查。而且医院有相应的奖励政策鼓励这种过度诊断和过度治疗。为了避免不正当的利益冲突，中国政府颁布法律禁止医生从药商拿回扣。即使按照中国的标准，中国医生的工资水平偏低。许多中国医生努力在职业道德要求和满足当下中国经济迅猛发展的形势下，寻找平衡点。这种压力交织中一些来自社会和政府对医生职业的贬值，驱使很多医生转行。如果不改善医生的社会和经济地位，中国的医药卫生体制改革将不会成功。中国医生应该更多的介入到医改过程，发出自己的声音，用自己的经验和建设性意见来帮助医改制度的完善。



Chinese doctors are under threat

System change, the theme of the World Cancer Congress in Shenzhen, China, Aug 18—21, was a central message in the opening address by the Chinese Minister of Health, Chen Zhu, as he described current health-care system reforms in China. At the Congress many international health policy makers and physicians led discussions on frameworks and actions for system change, but there was little participation from local Chinese doctors.
To understand why there were so few Chinese delegates in the plenary sessions on system change compared with sessions on patients' care, one must first understand that for many Chinese doctors personal safety is of greater concern. Chinese doctors are often victims of terrible violence. In June this year, a doctor and a nurse were fatally stabbed in Shandong Province by the son of a patient who died of liver cancer 13 years ago, and a paediatrician in Fujian Province was injured after leaping out of a fifth-floor window to escape the angry relatives of a newborn baby who had died under his care. Thus, it is not surprising to see that in July police officers were invited to be the vice-presidents of 27 hospitals in Shenyang. With hospitals turned into battlegrounds, being a doctor has become a dangerous job in China.
The problem may be largely one of perception. Many Chinese patients believe that doctors and hospitals conspire to increase charges by providing unnecessary examinations, investigations, and treatments. Additionally, some doctors accept red envelopes (a monetary gift in exchange for favourable service) against the rules. Many patients blame the deterioration of their health directly on doctors, claiming that doctors lack devotion and skills. The intellectual ideals of ancient China were “either to be a good prime minister or to be an excellent doctor”, while in modern China doctors and nurses used to be worshipped as “angels in white”. How has the perception of Chinese doctors become so eroded?
The Chinese media certainly have an important role in provoking tension between doctors and patients. There is disproportionate coverage in newspapers, television, and on the internet of how health professionals have cheated patients. Just a few weeks ago the Southern Metropolis Daily (the most popular newspaper in Guangdong) falsely accused a midwife, who had treated haemorrhoids for a patient after childbirth, of stitching the patient's anus closed on purpose. In November, 2009, one of China's most authoritative media outlets, CCTV (China Central Television), reported that the renowned Peking University First Hospital was carrying out illegal medical practices by allowing medical students to do surgical procedures, and as a result a patient had died. Even though the hospital and the Ministry of Health made it clear that involving medical students in clinical procedures including surgery under the supervision of licensed doctors is legal, trust in doctors and hospitals was seriously damaged. It is hard to tell whether the misreport resulted from a lack of medical knowledge on the parts of the Southern Metropolis Daily and CCTV, or whether it was motivated by a desire for a sensational story. However, the public misunderstanding of the medical profession will surely hurt both doctors and patients in the end.
Most hospitals in China, especially the large ones such as Peking Union Medical College Hospital and Huashan Hospital of Fudan University, are run by the government. Public hospitals in China enjoyed full government funding before 1985. After economic reforms, the hospitals now receive very limited financial support from the government, with the result that hospitals must generate income to cover costs. As the main source of hospitals' income is from diagnostics and treatment, there is a financial incentive to over-investigate and over-treat. To minimise inappropriate conflicts of interest, the Chinese Government passed laws to prevent doctors receiving financial kickbacks from drug companies. Because the standard salary of a doctor is modest, even by Chinese standards, many doctors struggle to balance professional ethics and making ends meet in an economically booming China. Such pressures, coupled with a sense of feeling seriously undervalued by the government and society as a whole, drive many doctors out of medicine into other jobs.
China's health-system reforms cannot be successful without reforming the social and economic status of doctors. Chinese doctors should be involved more in shaping health policy, by giving voice to their own experiences and constructive ideas about the health system.