Local hospitals in Shanghai inundated by patients. The average doctor in a top level hospital in Shanghai sees around 40 to 50 patients over a morning or afternoon shift. Photos: CFP

By Thomas McKinley

Upon visiting a local hospital in China, one may have the same impression as entering a large marketplace or bazaar – throngs of people, confusion, noise, and an initial complete loss of direction. As one is generally not in the mood for shopping around or bargaining at a hospital, it is nearly always a stressful experience.

As with many healthcare systems around the world, China's medical world suffers from a variety of ailments. Predictably, the theme of cost runs through nearly every aspect of what is in need of repair in the Chinese system – efficiency, doctors' training, and of course the treatment and attitude of patients.

Disrespected doctors

"Everything in China seems to discourage people from studying medicine," Dr Andrew Ngai, founder and managing partner of Shanghai Comfort Medical Group Ltd and head of St Reiss Medical Center in Shanghai, told the Global Times.

Chinese doctors struggle to be trusted by patients as there is a lack of faith in their skill and intentions. Coupled with the fact that local doctors are not nearly as well-paid as those in the West, a predicament emerges for those in the China's medical profession.

A case from last year, in which a woman named Li Ying stabbed a doctor in Yangpu district who had removed a benign tumor from her uterus, exemplifies this problem of perception.

The patient, claiming that she suffered pain as a result of the treatment, demanded compensation from the hospital, and then took out her anger physically when no money was forthcoming.

Cases in which patients confront doctors, often assisted by members of their immediate and even extended families, are not rare in China. "The entire family will financially contribute to pay for the expenses for one family member," said Luis Yan of Edding Pharm, a pharmaceuticals marketing company.

Another case which illustrates the decline of doctor-patient relations involves the storming of Xinhua Hospital in Yangpu by relatives of a deceased patient, who claimed that the hospital cut off the patient's medicine when he could no longer pay his bills.

While the hospital denies doing this, the wrath of the relatives, which consisted of holding a group of doctors hostage and stabbing six of them, was a clear manifestation of the lack of trust and understanding with which the general public views the medical profession.

"The education level of society, with regard to medicine, is low, and makes it difficult for doctors to explain medical situations," said Dr M, a senior local doctor at a Shanghai hospital who wishes to remain to be anonymous.

Dr Sheena Burnell, an anesthesiologist at Shanghai United Family Hospital, agreed. "The general public knows little about health issues or biological matters," she said, adding that Chinese patients tend to do very little of their own research on their illnesses, thus making visits to the hospital even more inefficient.

An effect of this, as described by Dr M, is that patients commonly try to bargain with doctors to lower the price of treatment.

The skill set

According to Dr M, some doctors view the profession as poorly paid, especially in relation to fields such as finance. "The government has traditionally taken a moral high ground and told doctors and nurses to 'sacrifice' – that it is their moral responsibility to help patients and ignore the low remuneration," he said.

The length of study to become a doctor, the lack of trust from patients, and the low pay have resulted in a "brain drain," that naturally militates against the development of the health sector. As Dr M concisely stated, "Doctors in China don't want their children to become doctors."

Training for local doctors begins with five years of undergraduate education, followed by one year of internship, one to two years' residency, and then specialization. In the West, there are five years of residency training.

"Local doctors specialize too early," Dr Ngai said. "This early specialization is a problem as the doctors are not generalists. The Western system has more general training and makes doctors more well-rounded."

While the training seems to fall short on the number of years spent studying, it also seems to err on being overly "academic," in the words of Dr Burnell. "Another dramatic difference between local and Western doctors is that the former have less hands-on experience.

Many Chinese doctors opt to go for a professorship, but this is really unnecessary," she said. The result is a large number of doctors who have the potential skills but not the practical experience.

One reason for this is the structure of the system, which consists of three "tiers." The first tier contains small community centers that primarily give vaccinations. Tier Two do surgery and medicine but are staffed by somewhat less trained doctors, while Tier Three are teaching hospitals, where senior doctors are sometimes called "professors."

Rich doctors may get their money from pharmaceutical commissions and from hongbao, two lucrative means which have been made illegal and cracked down on by the government.

Those at top level hospitals can get money from government subsidies and by having their academic papers published. "Although a 55-year-old 'professor' may only earn 8,ooo yuan ($1,217) to 10,000 yuan per month in salary, he may end up with one million per year," Dr Ngai said.

The system itself

The Tier Three hospitals, such as Huadong or Ruijin, are flooded with patients who could be treated elsewhere. According to Dr Ngai, patients opt not to go to Tier Two hospitals for three reasons. One reason is that Tier Two hospitals have less equipped diagnostic machines.

The second reason is that newer drugs are harder to come by, while the third reason is that the doctors working at Tier Two hospitals are viewed as less academic. "So patients go to Tier Three hospitals and the professor class of doctors have to treat simple cases. It's a waste of their time, and efficiency collapses," Dr Ngai said.

Kenny He, marketing director for Shanghai Unicept Management Consulting, which trains sales and marketing consultants for the medical and pharmaceutical industries, confirmed this and stated, "Doctors in Tier Three hospitals have a huge workload, about 40 to 50 patients during a morning or afternoon shift. They get a maximum of five minutes per patient."

According to Scott Rein, President of the Institute for Western Surgery, which brings senior physicians and surgeons over to China from the US, the huge concourse of people leads to hospitals basically forcing patients into a pattern of self-diagnosis.

The patients have to decide which doctor is best for their ailment. Adding to the confusion is the fact that different hospitals do not charge the same amounts for the same procedures. "Price disparity is a problem," said Dr Ngai.

Another complication related to costs is the fact that, according to Dr Ngai, 50 percent of patients in Shanghai's Tier Three hospitals are from outside Shanghai so many have to pay full fees as their national insurance does not cover them in Shanghai.

Such patients are encouraged by hospital administration as they increase revenue, however they also increase the burden on doctors.

The marketplace atmosphere reflects the poor patient-doctor relationship in China. During the past 20 years, the dynamic between the two has deteriorated to where patients act with suspicion and doctors react with paranoia.

This lack of trust generates a suspicious approach towards doctors – developing into what Dr M, who works at a Tier Three hospital, calls a "vicious cycle."

"Patients often insist on overtreatment, which doctors are afraid to advise against. Overtreatment is most patently seen in the overuse of MRI scans and the over prescription of pills.

Doctors are afraid to refuse an MRI, because they are afraid to take responsibility – so they over prescribe to avoid being sued," said Dr M. "In China, there are 60-80 MRIs a day per hospital; in the US, there are 20-25." Dr Ngai puts the Chinese figure even higher at between 150 and 200 for large hospitals.

New MRI machines are bought by hospitals every year. The drain on hospital budgets due to the purchase of expensive machines affects the hospital's bank balance, and an attempt is made to compensate for this by the over prescription of pills.

"This is an auto-adjustment of the market: more of everything enables everyone to pay their bills. But society ends up paying more," said Dr M.

Kenny He stated that "50-55 percent of a hospital's income comes from drug prescriptions," a statement confirmed by Luis Yan who stated, "As government funds only cover a small fraction of what is required by the hospital, the hospitals have to rely on drug revenue as their main source of profits.

This is why, in China, hospitals and pharmacies are combined in one unit. If you are treated in a particular hospital, you must buy drugs from their pharmacy."

Dr M contended that it is the system itself, and not the fault of doctors or patients, that is responsible for the inadequacy of the healthcare situation. He first cited costs as a major factor.

"Local hospitals are simply too cheap," said Dr M. The price of a visit to a hospital, which can be as low as 20 yuan, encourages people to visit a hospital for even the slightest illness. The result is the inundation of patients which leaves doctors little choice but to be overly efficient and even a bit abrupt.

This leads to a perception on the part of patients that doctors are apathetic and dismissive, leading to an overall negative view of members of the medical profession.

As Dr Burnell stated, "In China, there is a tendency for local doctors to treat patients like objects. The relationship is very ‘transactional.'" Nevertheless, Dr Burnell, along with other doctors interviewed by the Global Times, is quick to absolve local doctors from having the blame for this attitude.

Rather, they also attest that the local system itself is responsible. "Chinese doctors are under enormous time stress," Rein said.

The crowding and inefficiency naturally have a disastrous effect on doctors' bedside manner with patients. While Parkway Healthcare, a Singapore-invested joint venture hospital, requires doctors to spend 30 minutes minimum per patient, local doctors try to fit in as many patients as possible.

According to Dr M, a typical visit to a non-specialist doctor lasts two minutes, while a visit to a specialist is between five to 10 minutes. As for nurses, Rein asserted that "Chinese nurses are well trained technically, but they have no bedside manner."

Compounding the effect of inexpensive costs is the amount of people visiting a hospital several times for a chronic condition such as hypertension or diabetes. "There is a 'ceiling' on what you can spend as a patient each time you go. So you need to visit the hospital several times to get the full prescription. This creates logistical difficulties and simply a lot more work," Dr Ngai said.

Summing up the costs aspects of the system, Dr M said, "the government wanted to lower medical prices, but forgot one thing: doctors and nurses work hard and want to be paid properly."

However, conditions may improve. Earlier this month Xinhua news reported that Shanghai's public health service plans to introduce a family-doctor style of health care within the next five years to alleviate the pressure on hospitals, according to Shanghai's vice mayor Shen Xiaomin.

Under the plan one doctor will be in charge of 2,000 to 3,000 patients and consultations will be done both face-to-face and online. Residents will be required to set up an online health record for the doctors to reference.

The second part of this report on healthcare in Shanghai will appear on February 25.