Doc­tors look to break pub­lic sys­tem shack­les

Med­i­cal pro­fes­sion­als are push­ing for greater open­ness in the reg­is­tra­tion mech­a­nism that can tie them to a sin­gle es­tab­lish­ment for their en­tire ca­reer, as re­ports for Xinhua China Fea­tures.

China Daily (Hong Kong) - - CHINA -

De­spite ap­peals by his su­pe­ri­ors, gy­ne­col­o­gist Kang Kai was de­ter­mined to re­sign from the hos­pi­tal in which he had worked for nearly 20 years.

He said he left “for free­dom and re­spect”.

Kang, 45, worked at a lead­ing pub­lic hos­pi­tal in Chongqing, South­west China. In the eyes of his col­leagues and pa­tients, the gray-haired doc­tor was em­i­nent and re­spectable, but he de­scribes him­self as a slave: work­ing around the clock, with just half a day off each week and “al­ways ready for over­time”.

As head of the gy­ne­col­ogy depart­ment, Kang was re­spon­si­ble for deal­ing with hun­dreds of ad­min­is­tra­tive in­spec­tions, meet­ings, med­i­cal dis­putes and stud­ies that took up a huge amount of his time ev­ery year for no ex­tra pay

He also dealt with strained doc­tor-pa­tient re­la­tions that could re­sult in vi­o­lence. Kang was even threat­ened twice him­self.

“It was very dis­heart­en­ing,” he said. “I didn’t want to work that way.”

In 2015, he moved to Bei­jing and be­came a free­lance spe­cial­ist, see­ing pa­tients at dif­fer­ent hos­pi­tals, mainly pri­vate ones. Last year, unit­ing about 100 lead­ing doc­tors na­tion­wide, Kang set up Woyi, which means “fer­tile ground for doc­tors”, China’s first group for gy­ne­col­o­gists.

He is one of a grow­ing num­ber of Chi­nese doc­tors of­fer­ing their ser­vices out­side the pub­lic hos­pi­tal sys­tem where they made their rep­u­ta­tions. “I feel like a fish swim­ming from a pond to an ocean,” he said.

Im­bal­ances

Giv­ing doc­tors the free­dom to choose where they see pa­tients helps to tackle China’s chronic im­bal­ance in med­i­cal re­sources, ac­cord­ing to Kang.

About 80 per­cent of the coun­try’s med­i­cal re­sources are found in big cities, such as Bei­jing and Shang­hai, and 30 per­cent of them are in big pub- lic hos­pi­tals, which are flooded with pa­tients ea­ger to see em­i­nent physi­cians.

The process of see­ing a doc­tor at a big hos­pi­tal is a mis­er­able one. The sick must line up overnight for tick­ets, com­pet­ing with scalpers, whose prices can be 1,000 times the of­fi­cial fee.

The time a doc­tor has for each ap­point­ment is tight. Kang once saw as many as 80 out­pa­tients a day, each for just 2 or 3 min­utes. “It was the only way to get away from work at a rea­son­able time,” he said.

Doc­tors grum­bled about “be­ing nailed to a chair all day” without even time for a toi­let break, Kang said.

He ad­mires how med­i­cal staff in the United States and Europe can work for more than one hos­pi­tal, ei­ther pub­lic or pri­vate. More­over, thanks to the hi­er­ar­chi­cal med­i­cal sys­tems in those re­gions, pa­tients can re­ceive high-qual­ity ser­vices at nearby clin­ics.

In China, med­i­cal staff and fa­cil­i­ties are in great de­mand, so hos­pi­tals strug­gle to at­tract and re­tain good doc­tors. In 1999, a law was passed that re­quired doc­tors to be reg­is­tered with one hos­pi­tal, which would be re­spon­si­ble for their pay, wel­fare and pro­fes­sional po­si­tion un­til re­tire­ment.

Doc­tors who were not reg­is­tered with a med­i­cal in­sti­tu­tion were of­ten con­sid­ered quacks.

The reg­u­la­tions be­gan to be eased in 2009, when the State Coun­cil pub­lished a plan that al­lowed doc­tors to of­fer their ser­vices at more than one hos­pi­tal. In Oc­to­ber, the gov­ern­ment re­leased the Healthy China 2030 blue­print to “ex­plore the prac­tice of free­lance physi­cians and doc­tor groups”.

Reg­u­la­tions is­sued in March also sup­ported doc­tors who want to run their own clin­ics.

Ris­ing salaries

Kang said al­low­ing doc­tors to reg­is­ter at more than one hos­pi­tal gives pa­tients im­proved ac­cess to treat­ment, and helps un­der­paid doc­tors earn more, be­cause they can work at pri­vate hos­pi­tals, which of­fer bet­ter pay than the pub­lic sys­tem.

Pa­tients have lam­basted doc­tors in pub­lic hos­pi­tals for com­mis­sion­ing need­less scans and other tests to make more money.

How­ever, Kang pointed out that an ap­point­ment at a pub­lic hos­pi­tal with an as­so­ciate se­nior doc­tor, such as him­self, would cost 15 yuan ($2.20) — less than a hair­cut — and he would re­ceive a “neg­li­gi­ble” share of that.

In pri­vate hos­pi­tals, a con­sul­ta­tion costs 450 yuan, and he re­ceives half of the fee.

Kang ad­mits he had no idea how much a con­sul­ta­tion should cost at first: “We left the de­ci­sion to the mar­ket.”

He used the ex­am­ple of a fe­male doc­tor who of­ten works late be­cause her con­sul­ta­tions last longer than those con­ducted by other col­leagues. Even though her con­sul­ta­tion fee has risen from 450 to 800 yuan, she still has many pa­tients.

“Doc­tors wouldn’t take kick­backs,” Kang said.

High fees dis­cour­age price­sen­si­tive cus­tomers, but Kang ar­gued that pa­tients see doc- tors much more quickly than they would in a pub­lic hos­pi­tal.

Univer­sity teacher Jia Hong gave birth this year at a pri­vate hos­pi­tal in Bei­jing. The med­i­cal bill was 30,000 yuan, more than 10 times that in a pub­lic hos­pi­tal, but she didn’t care. “It’s ex­pen­sive, but it saves time, and I did not have to pre­pare a red en­ve­lope (a gift of money),” she said.

How­ever, few doc­tors are throw­ing off their “shack­les”. By last year, just 3,000 doc­tors had ap­plied for ex­tra reg­is­tra­tions, less than 5 per­cent of the to­tal num­ber in Bei­jing. In Jiangsu prov­ince, only 1,000 doc­tors have ap­plied since 2010.

Pub­lic hos­pi­tal ad­min­is­tra­tors have mounted strong op­po­si­tion to the move, be­cause they fear doc­tors will take pa­tients and prof­its to pri­vate hos­pi­tals.

Last year, two oph­thal­mol­o­gists made head­lines af­ter be­ing fired from a lead­ing pub­lic hos­pi­tal in Bei­jing for “steal­ing pa­tients”.

Doc­tors now worry that pub­lic hos­pi­tals will ex­tract ret­ri­bu­tion by af­fect­ing pay, pro­mo­tion prospects and pro­fes­sional ti­tles.

Many doc­tors who joined Kang’s group were per­suaded to aban­don their move by their hos­pi­tal bosses.

Lack of pa­tients

An­other prob­lem fac­ing free­lance medics is the lack of pa­tients. Dur­ing his tough­est pe­riod, Kang had just one pa­tient a day.

Zhang Qiang, a lead­ing vas­cu­lar sur­geon from Shang­hai who be­came the coun­try’s first free­lance doc­tor, also suf­fered a loss of pop­u­lar­ity: “Be­fore I quit the pub­lic hos­pi­tal, I had about 200 op­er­a­tions to do, but when I ran my own busi­ness, only five pa­tients fol­lowed me. It’s re­ally a big test for doc­tors.”

Ac­cord­ing to Kang, China’s top hos­pi­tals are all Sta­te­owned, and they have the most-ad­vanced med­i­cal equip­ment and the best­trained med­i­cal staff.

“De­spite of­fer­ing all these ser­vices, doc­tors never learn, or need, to please their pa­tients. Af­ter leav­ing pub­lic hos­pi­tals, they don’t know how to com­pete in the mar­ket. We have to be nice to pa­tients, be­cause they are cus­tomers,” he said.

Build­ing brands

To reach the pub­lic, free­lance doc­tors are tak­ing to so­cial me­dia and apps to pop­u­lar­ize med­i­cal science.

More than 2,000 health­care apps are avail­able to en­able users to con­tact doc­tors ei­ther by in­stant. mes­sage or phone. Their con­ver­sa­tions are open to other users, who can as­sess a doc­tor’s ser­vices and skills at a glance, rather than by re­search­ing their qual­i­fi­ca­tions. Some have mil­lions of fol­low­ers.

“In the past, doc­tors waited for pa­tients, but now we look for pa­tients,” Kang said.

While some ex­perts pre­dict that China will see an up­surge in the num­ber of free­lance doc­tors in the next 15 years, Kang said there’s still a long way to go. “Few peo­ple would pay more to see a doc­tor at a pri­vate hos­pi­tal,” he said.

More­over, on­line con­sul­ta­tion comes with the risk of mis­di­ag­no­sis or dis­clo­sure of per­sonal in­for­ma­tion. Pa­tients of­ten become an­gry at high fees, lead­ing to dis­putes at pri­vate hos­pi­tals, which still re­quire gov­ern­ment scru­tiny and reg­u­la­tion.

Duan Tao, a for­mer pres­i­dent of the Shang­hai First Ma­ter­nity and In­fant Hos­pi­tal and now a free­lance doc­tor, urged pub­lic hos­pi­tals to re­duce work­loads by can­cel­ing un­nec­es­sary ad­min­is­tra­tive meet­ings and in­spec­tions.

“In a word, give time back to the doc­tors, and give the doc­tors back to the pa­tients.”

I feel like a fish swim­ming from a pond to an ocean.” Kang Kai, a doc­tor who used to be em­ployed by a pub­lic hos­pi­tal in Chongqing, but now works as a free­lance spe­cial­ist in Bei­jing

LIANG XU / XINHUA

A pa­tient con­sults a doc­tor at a pri­vate clinic in Guangzhou, Guang­dong prov­ince.

YU TIAN / FOR CHINA DAILY

A woman holds her baby in a crowded pub­lic hos­pi­tal in Nan­jing, Jiangsu prov­ince.

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