Photo Courtesty U.S. Pacific Fleet
Asia-Pacific / Healthcare

The Rise of Patient-on-Doctor Violence in China

In March 2012, Dr. Wang Hao was working as an intern in the rheumatology department at the First Affiliated Hospital of Harbin Medical University in Harbin, China. Upon entering the hospital, he made plans for a dinner date and karaoke session with a fellow nurse and then sat down at his computer to begin his night shift. As Dr. Wang was beginning his pre-shift routine, Li Mengnan, a 17-year-old patient unsuccessfully treated for spinal inflammation, purchased a generic fruit knife across the street. Within the next twenty minutes, Mengnan arrived at the hospital, saw Dr. Wang’s white coat, and proceeded to stab the kitchen utensil three inches deep into his neck. Surrounding hospital workers tried to rescue Dr. Wang, but Mengnan cut the ear and face of one more physician and slashed two other physicians, none of whom he had previous contact with.

Each year in hospitals across China, in both urban and rural areas, unsatisfied patients are maiming and even murdering doctors and nurses with lead pipes, knives, guns, and even umbrellas. These incidents of patient-on-doctor violence have been escalating in frequency and brutality. According to a survey conducted by the Chinese Hospital Association, there were an estimated six hundred and twenty thousand incidents of patient-on-doctor violence in 2012. Between 2008 and 2012, the proportion of Chinese hospitals reporting violent conflicts between patients and healthcare providers increased from 48 percent to 64 percent, and the average number of violent attacks (verbal abuse and threats that turn into beatings and even murder) directed at healthcare workers in each hospital increased almost 30 percent. In the last five years, patient discontent and abuse of physicians has become the norm, so less public and media attention has been focused on hospital disputes. But this healthcare issue, which threatens the safety of doctors nationwide, indicates many disconnects that have collectively led to a national healthcare crisis.

Many of China’s healthcare components cannot compare to those of its western counterparts (e.g., United States, United Kingdom, France), which may offer an explanation as to why increasing patient-doctor violence is a phenomenon most strongly associated with China. In America, the average appointment lasts 20.3 minutes, while in China the average doctor’s office visit lasts about seven minutes, one and a half minutes of which the physician actually communicates with the patient. The physician to patient ratio also presents a shocking healthcare disparity between western countries and China. While Western countries have about 12.83 medical workers to every one thousand patients, China has only 3.83 medical workers to every one thousand patients. The record high of patients seen by one doctor in Shanghai was three hundred patients in one day. Under these circumstances, appointments are bound to be rushed, impersonal, and ineffectual. This lopsided patient to doctor ratio puts further burdens on doctors with too little time and too many patients, and it perpetuates the cycle of underfunded and overcrowded Chinese hospitals. Furthermore, public hospitals do not allow scheduled appointments. Instead, patients or family members of patients must arrive early for a call number and appointment slot the day of, and they sometimes wait up to four hours to see a doctor for four minutes. Instead of a process similar to visiting a hospital in America, it is more similar to a visit to the DMV. The violence against doctors can also be attributed to rising medical bills, widespread corruption in the medical field, and a general disrespect for doctors.

There is a Chinese saying, “kan bing nan, kan bing ku,” which means, “to see a doctor is hard, to see a doctor is expensive.” In a survey study referred to in Forbes, 81 percent of the respondents (Chinese citizens) claimed it was challenging to see a doctor and 95 percent of the respondents said that it was expensive to seek professional medical care. The price of medical treatment has only increased with time. From 1993 to 2008 the price of an outpatient visit increased by 620 percent and the price of an inpatient visit increased by 473 percent. This trend is also represented in the average price of overnight hospital stays. The average price of one hospital stay in 1993 was around 74 percent of a rural resident’s annual income and 80 percent of an urban resident’s annual income. A decade later, the overnight hospital fee escalated to twice as high as an individual’s annual income for both the urban and rural dwellers. So when patients decide to foot the unaffordable medical bill by depleting their life savings or going in debt, they are expecting quality care and good results. In theory, if patients are willing to pay such high prices, doctor efficacy should also be high. But when doctors do not deliver the best treatment or positive results, the patient is left not only destitute but also uncured and frustrated. This frustration is expressed in the form of violence on the only clear targets: physicians.

Corruption among a majority of healthcare officials in China also contributes to the violence by breeding distrust between patients and doctors. In many hospitals, the more drugs a doctor prescribes, the more money he earns from pharmaceutical companies. In fact, 75 percent of patients with a common cold are prescribed antibiotics, well over twice the international average of antibiotic prescriptions at 30 percent. Chinese doctors also expect a bribe, refusing to offer the best treatment or even any treatment if the patient doesn’t provide extra compensation. This practice has become so widely accepted that even to receive service or quality care, a patient must give his or her doctor a gratuity in the form of either a red envelope filled with cash or an expensive gift. Supplemental kickbacks not only further boost prices, but patients have a preconceived notion, founded on personal experience, that most doctors are dishonest, greedy, and legally and administratively unsupervised. According to Yanzhong Huang, a senior fellow for Global Health at the Council on Foreign Relations, frustrated patients without “legal, institutionalized channels to address the disputes” can only “rely on violent means” to voice their discontent.

Another reason for this physical mistreatment of doctors is their lack of social standing. Doctors assume a prestigious position in America, but in China they are seen merely as civil servants. In the United States, it is well known that doctors have had to complete a rigorous academic agenda to become certified practitioners. But both Chinese history and current practices breed suspicion and negative attitudes toward doctors. Hua Tuo, a surgeon in the second century A.D., warned a military general of a brain tumor. Suspected of a murder plot, he was executed in the first case of patient-on-doctor violence. Xu YanZuo, a Qing dynasty scholar, wrote, “Rarely do people die of diseases; they often die from medicine.” By the time China experienced the Cultural Revolution in the mid twentieth century, the most prevalent, affordable, and accessible doctors were the “barefoot doctors.” These were rural peasants who received minimal medical education and were expected to assist and cure various ailments and injuries that they had never encountered. Although these “doctors” were numerous, they were all limited in training and medical equipment, failing to provide sanitary treatment and anything beyond the most basic healthcare.

This negative historical bias has only escalated in recent years, inciting a response in doctors as well. Eighty-nine percent of doctors have considered leaving their current job and career. More than 70 percent of doctors and nurses are verbally and physically abused, chances of occupational advancement or raises are rare, and there is a lack of security insurance, making their career potentially more damaging than profitable. While the average monthly American physician’s salary is around $13,000, the official average monthly physician salary in China is a meager $500. Even more surprising, these underpaid doctors are working just as much or even more than a full time physician in America. A different survey discovered that doctors worked 6.5 days each week for about 9.97 hours a day on average. A majority of the respondents worked seven days a week, and almost 90 percent of the respondents expected to work overtime during the holidays. Under these conditions, doctors are not inclined to provide quality care for minimal compensation, and future generations are put off from the medical field. Only one sixth of students who graduate from medical school in China choose to pursue a career as a hospital physician, which creates a dearth of doctors and a larger group of untreated and unsatisfied patients. With a shift away from the disengaged attitude that doctors have recently adopted, it may be possible to indirectly curb incidents of patient violence.
According to a survey conducted by the Pew Global Attitudes Project, apprehension about China’s healthcare system has more than doubled in recent years. Shoddy hospital infrastructure, widespread corruption, and lack of doctors all increase popular anxiety and contribute to patient-doctor violence. Neither patients nor doctors are wholly responsible for the violent episodes that have plagued many of the nation’s hospitals. Because patient-doctor violence has its roots in numerous systemic failures, the only plausible solutions for preventing further patient aggression and doctor maltreatment are to make healthcare more affordable and accessible, regulate doctor activity in regards to corruption, increase quality of care by re-adjusting salaries and work loads, and create a more open lineof communication between patients and physicians. If China adopts these comprehensive reforms, the new healthcare system could potentially placate patient-doctor relationships.