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[Editorial] The doctors' predicament: China's health-care growing pains

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The Chinese characters for doctor also refer to scholar-bureaucrats, which was the highest aspiration for intellectuals in ancient China. Doctors were then respected as much as Confucian elites who were supposed to have high moral standards and be well educated, altruistic, and dedicated to serving the country. However, in modern China, medicine is no longer seen as a noble or an attractive profession. Last week, four officials were removed from their posts on the basis of their negligence in reviewing and approving an anti-gang brochure in which doctors were portrayed as gangs and listed as first among the top ten gang categories in China. Furthermore, the nation's health-care services were described as a “black-hearted enterprise” with “no conscience while collecting money”.

The publication and dissemination of the brochure revealed Chinese society's negative perception of doctors. Additionally, it struck a damning blow to the already declining and fragile morale among all levels of doctors in China. According to the Chinese Physicians' Practice Status White Paper released by the Chinese Medical Doctor Association in 2018, half of all health professionals did not feel well respected and 45% of doctors did not want their children to pursue a career in medicine. With repeated headlines showcasing the deteriorating doctor–patient relationship, as well as violence against doctors over the past decade, it is not difficult to understand why so many medical graduates choose not to enter the profession after graduation or qualification. Despite efforts to protect doctors in China, 62% of doctors did not find any improvements in their medical practice environment between 2016 and 2017, as the White Paper reported.

The striking contrast between the social status ascribed to Chinese doctors today and that they were given in the past is truly shocking and disappointing, but it can also be viewed as growing pains of a health-care system undergoing massive societal and economic transition. As President Xi Jinping said at the 19th National Congress of the Communist Party of China, “the principal contradiction facing Chinese society in the new era” was that “between unbalanced and inadequate development and the people's ever-growing needs for a better life”. The pursuit of a better life naturally translates into unprecedented high expectations for better health-care services. However, the health-care system's development lags far behind the rapidly growing needs for better quality of care. An immature primary health-care system and a hospital-dominated care delivery system compound the challenges faced by health-care professionals, such as the huge workload and expanding medical disputes.

Health-care systems cannot be changed overnight, but a more rapid response to Chinese doctors' discontent in their roles, and providing support for doctors to improve their practice, could be steps towards promoting modern medical professionalism. Indeed, China has a long tradition of medical professionalism. The ancient beliefs, built upon Confucian ethics, that doctors are healers with benevolent hearts, still holds true today. Each medical student will vow to “strive diligently to eliminate human suffering, enhance human health conditions and uphold the chasteness and honor of medicine” on the first day of medical school. Nevertheless, the gap between what doctors are trained to do and the realities of modern medical practice is widening. As the doctor–patient relationship progresses from a paternalistic model to one of mutual participation, doctors are expected to be partners, listen to their patients, and involve them in shared decisions. Furthermore, modern medical professionalism requires that doctors advocate on behalf of their patients, particularly when it comes to patient safety. It is every doctor's professional duty to raise concerns of poor care and to communicate mistakes to patients honestly and transparently. Both will increase trustworthiness. Research and innovation are also important for the development of health care, and it is essential for doctors at every level to support progress in research and to deliver evidence-based care.

To give a voice to Chinese doctors' predicaments, The Lancet will soon initiate a new editorial project—a Chinese version of our Wakley Prize. Since 1996, The Wakley Prize is awarded annually for the best original essay on any topic of importance to medicine and health, in memory of the founding editor of the journal, Thomas Wakley. For the Chinese version, we will invite essays on medical professionalism written in Chinese, so that more Chinese doctors can speak up about their own stories and concerns in medical practice, which we hope will contribute to enhancing patient care in China.
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