Practising medicine in China: an unsolved dilemma
Authors: Yun Tian, Yu Hu, Ping Chen, Zhe Tang, Chang-Qing Gao
Journal: Journal of the Royal Society of Medicine (2011)

China's healthcare system has undergone an evolutionary change in the past six decades. Between 1952 and 1982, China's healthcare system achieved some significant milestones. Specifically, the infant mortality rate decreased from 200 to 34 per 1000 live births, the life expectancy nearly doubled, and China gained control of infectious diseases, such as malaria and schistosomiasis.1 The ‘barefoot doctors’, who receive limited training, but are supported by the government, provide basic services at a very low cost to the countryside where the majority of the population lives.2 Since the launch of economic reform in 1978, China's healthcare system has been transformed. Between 1978 and 1999, the central government's share of national healthcare spending was reduced from 32% to 15%, leading to predictable sequelae.3 Indeed, the reduction in national healthcare spending forced healthcare providers to rely on the sale of services, such as high-tech tests and expensive pharmaceuticals, as a means to increase profits and resulted in the increase of out-of-pocket payments from 20% in 1978 to 58% in 2002, thus forcing many families into poverty.4 The public has not been happy with the wrenching changes in their healthcare system.

As a result of these issues, the Chinese government has long sought to reform its healthcare system. On 6 April 2009, the government released its long-awaited new guidelines on healthcare reform.5 The enactment of new guidelines marked the beginning of a new era in healthcare in China, a moment that was widely welcomed by the population.6 Under the reform plan, over 90% of China's population will be covered by one or another health insurance scheme by 2011, rising from 15% in 2003. According to the information released by the State Council's Office of Health Care Reform, the government had put 71.6 billion Yuan (US$ 10.5 billion) into the reform plan by mid-2009.7

In addition to the healthcare system, Chinese physicians have long been criticized by the public for inappropriate conduct, such as taking ‘kickbacks’ from pharmaceutical companies. There are also cases in which surgeons, along with other senior specialists, have been found guilty of taking under-the-table payments from grateful, or even fearful, patients.8 Not surprisingly, patients often feel that they are being treated unfairly and that there exists inequalities in their care. There have also been instances in which the relatives of patients have taken medical professionals hostage in order to bargain with hospitals to meet their needs. In June 2009 alone, there were five incidents reported from different healthcare facilities in which one nurse was killed and more than 10 health professionals were stabbed by the relatives, or people hired by the relatives, of patients.9 Similar events have been happening continuously.10,11

While being criticized, and sometimes even mistreated by patients and their relatives, physicians in China have rarely expressed their opinions in the media. The opinions of physicians regarding topics in healthcare and job satisfaction have not been disclosed. A 2003 study by Lim et al. reported physicians' opinions of the healthcare situation.12 The authors surveyed 720 medical professionals in three provinces of China from both rural and urban areas, as well as public and private domains, in equal numbers. The study showed that only 32% of physicians supported the healthcare system of that time. Moreover, only 8% of physicians were satisfied with their income, 27% were satisfied with their job, and 30% were satisfied with their level of skills.


Six years later (in August 2009), based on our investigation in Beijing, Tianjing, and other provinces involving 633 physicians, of which 37% had worked as physicians for over 10 years, from all levels of public and private sectors, we found the following: 


87.2% believe that the current environment of medical practice in China is not satisfactory, 6.1% believe the current patient–physician relationship is adversarial, and 4.5% believe the professional environment has reached the worst possible extreme. Further, 43.9% of physicians have been vigilant while working so as to avoid being attacked by patients and their relatives;


57.4% believe the remuneration they receive is too little for the efforts they put forth in their work;


52% would prefer that their children do not study medicine in the future;


37.5 % of physicians feel there is an immediate necessity to improve their clinical skills.



Based on these surveys, it is clear that physicians in China are responsible professionals who care about the quality of healthcare and the safety of their patients. They are eager to improve their skills and are willing to engage in continuing medical education in order to benefit society. They are disappointed with the current payment system and professional environment, and they are not optimistic about the future of their profession in the long term.


Yet, the reform brought some hope for physicians in China. In our investigation, 70% of physicians expect an increase in income, and 79% expect a better patient–physician relationship with the healthcare reform. That is to say, the majority of physicians cling to the hope that the reform of the healthcare system will result in improvement in their financial status as well as their professional environment. This is crucial for the reform, as the participation of physicians in the reform is essential.

Indeed, previous studies have shown that a physician's satisfaction is correlated with productivity and performance, as well as patient satisfaction.13 The success of healthcare reform in China will certainly be related to physicians' support, participation, and satisfaction. Therefore, the frustration of physicians must be addressed during the process of healthcare reform. Only when both physicians and patients are satisfied, in addition to other parties, can reform truly be considered a success.