My uncle in China was recently hospitalized - having come dangerously close to a stroke. Doctors recommended that he undergo surgery, but to my surprise, he refused. “These doctors are always after your money,” he said to me. “They make the situation seem more serious than it actually is. You have to trust doctors, but never completely.”

I feared the worst if my uncle didn’t go through with the surgery and I became frustrated when he refused to listen; however, the more I learned about the Chinese medical system, the more I could understand his decision.

Danger on the Front Line

China’s hospitals are plagued with distrust, corruption, and fear. Patients and their families must constantly fight to receive better medical treatment, while physicians operate within a restrictive system that limits their ability to practice. I recently met with Dr. Xiang, a distant relative and oncology physician who shared his experiences with me. “Life is hard for physicians in China. We are paid a very small salary, receive little respect, and are constantly blamed. While an American physician can easily support a family of 4 and live in a large house, I can barely support even one child on my salary alone.”

Due to the long hours and low income, some physicians look for ways to earn extra revenue. This often involves spreading rumours about possible accidents during surgery and accepting hongbao (bribes) to guarantee extra care is taken. Some physicians prescribe unnecessarily expensive medication in order to earn more profit.

After my uncle’s health assessment, the physician passed the medical results directly to his daughter. I was confused as to why my uncle wasn’t allowed to make an informed decision regarding his own treatment. “Physicians are in a dangerous position, being on the frontline of healthcare, “ explained Dr. Xiang. “Despite us having the medical expertise, patients are paranoid about the treatment they are prescribed. If anything goes wrong, despite no one being at fault, patients will blame and sometimes physically attack their physician out of rage. Physicians have been killed or seriously injured this way, therefore we prefer to tell the family instead of the patient directly.” According to a recent news article, angry family members can also be a serious danger.

Runaway Patient

Dr. Xiang: “We are often accused of being heartless for turning away patients who can’t afford treatment, but we have no other choice. In my early years of practicing, a migrant worker brought in his elderly father who required surgery. He couldn’t pay upfront, so I agreed to charge the majority of the fee after a few days of hospitalization. After spending 9000 RMB of hospital resources on the patient’s treatment, the migrant worker ran off with his father in the middle of the night. As the one responsible for the case, I would be personally held liable if I couldn’t track down the patient. I called the patient’s home multiple times and even went to ask for the money in person – no response. The police wouldn’t even take on the case. In the end, I was lucky that the hospital was willing to cover the medical fees, but I knew they wouldn’t be willing to do it a second time. I learned my lesson – always ask for the fee upfront otherwise suffer the consequences. Patients can’t be trusted.”

The Hierarchy

Chinese physicians operate in a three level system. First-level physicians are department heads, second-level physicians act as floor managers, and the third-level physicians see patients directly. Third-level physicians are the least experienced and are responsible for collecting all patient medical details. This information is passed up to second-level physicians for diagnosis. In particularly difficult cases, the responsibility for diagnosis reaches the first-level. This means that the physicians who diagnose illnesses have limited contact with the patients themselves. At most, first-level physicians see patients once a week.

There are of course many problems that arise: new physicians do not gain the experience of diagnosing illnesses, there is a high probability of miscommunication, and third-level physicians are often blamed for the decisions of their superiors. In addition, physicians' incentives structure rewards published academic papers over quality of patient care provided.

Decades of civil unrest have sown distrust into the fabric of Chinese society, and the design of its healthcare system has only worsened this. “Healthcare in China is flawed on too many levels,” said Dr. Xiang. “It will be many years before we see any real change happening, but I am certain it will happen.”

In the end, my uncle chose to see a traditional Chinese medicine doctor near his village. He was advised to stop working his 80 hour weeks in the factory and is now resting at home. Thankfully his crippling headaches and dizziness have ceased, and I am breathing a long sigh of relief that he’s out of that Chinese hospital.