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Doctors look to break public system shackles

Yuan Quan

(China Daily)

Updated: 2017-07-26

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.


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 public 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 price-sensitive customers, but Kang argued that patients see doctors 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 State-owned, and they have the most-advanced medical equipment and the best-trained 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." 


Link: China's Central Government / World Health Organization / United Nations Population Fund / UNICEF in China

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