Time to rebuild the doctor-patient relationship in China

In China, the doctor-patient relationship (DPR) has been tense in recent years and continues to deteriorate. From 2009 to 2018, 295 severe medical violence events were reported on social media, in which 362 doctors were injured and 24 lost their lives (1). According to a survey conducted in 2018 by the national Chinese Medical Doctor Association (CMDA), 62% of doctors had experienced varying degrees of medical disputes and 66% had experienced varying degrees of doctor-patient conflict, dominated by verbal violence (accounting for 51% of cases). Doctors’ satisfaction with their profession was significantly lower compared with that among the average social reference group, and 45% of doctors didn’t want their children to work in the medical profession, reflecting a lack of confidence in their profession. The DPR in China appeared to hit the bottom when an emergency physician, Wen Yang, was stabbed by a patient’s son in an extremely cruel way on 24^th Dec 2019 (2).

The outbreak of coronavirus disease 2019 (COVID-19) seemed to be a turning point for the DPR in China. From the beginning of 2020, millions of doctors worked on the front line of the pandemic, and the majority of the public were extremely grateful. A few studies demonstrated that the DPR in China improved and the level of doctor-patient trust increased during COVID-19 (3). However, this notion has since been questioned. Violence has continued to occur, and the data isn’t consistent with the notion. According to the results of an advanced search of Alpha (https://promote.alphalawyer.cn/), a powerful functional legal search platform in China, the total number of medical damage liability disputes in 2020 was 18,670, revealing an increase of approximately 3% compared with that in 2019, and an increase of approximately 50% compared with that in 2018. Additionally, a survey conducted in 2021 by the Tsinghua University department of sociology Humanistic Medicine Committee of CMDA showed that there was no improvement in DPR or self-professional recognition from doctors’ perspectives.

Doctors in China are often praised as heroes when needed while treated with suspicion and subjected to violence when not needed. The current polarization of the DPR in China warrants serious consideration and may involve multiple factors. From doctors’ point of view, doctors are exhausted and overly stressed in China, especially those in tertiary hospitals, which lays hazards to the DPR. Because of the unequal distribution of medical resources, the hierarchy of the hospital system is an important consideration for Chinese patients, who trust tertiary hospitals far more than primary medical centers. Since the underdeveloped referral system, most patients choose to go directly to tertiary hospitals regardless of the severity or type of disease, leading to an excessive clinical workload for doctors in tertiary hospitals. The accumulation of patients also leads to long waiting time and short reception time, which are potential triggers for doctor-patient conflict. As a result, it is not surprising that over 70% of recorded patient-doctor disputes occurred at tertiary hospitals, despite tertiary hospitals accounting for only 1.5% of all medical centers in China (1). Moreover, the current promotion system excessively focuses on scientific research (e.g., the number of published articles, impact factor, foundation projects, etc.) and insufficiently focuses on clinical work. The pressure to maintain scientific output in addition to heavy clinical work is extremely high. From the patients’ point of view, DPR carries its own negativity. People are often already experiencing fear and anxiety when they find out that they or their family members may be sick. Deficient medical knowledge and excessive concern for loved ones often lead patients to have unscientific and overly high expectations. Modern medicine has limitations and doctors are not omnipotent. When doctors fail to meet unrealistically high expectations, dissatisfaction may be triggered.

Negative medical news is always engaging and has disastrous effects on the DPR in China. Many media outlets report one-sided and inaccurate news with attention-grabbing headlines (e.g., “A pregnant woman died in the operating room and doctors and nurses missing!”). However, the full texts of these articles often contain no objective scientific description of the patient’s disease or the treatment process, instead providing descriptions of the patient’s life struggles and difficulties. The impact of negative news can spread within several hours, with a higher level of attention 72 hours after the news is issued and an exponential decline thereafter in the current information age, which means that even if a subsequent clarification regarding inaccurate negative doctor-patient news is reported, the negative impact of the inaccurate report still exists and cannot be completely eliminated. Many media outlets continue to compress the news cycle in pursuit of timeliness nowadays, degrading the accuracy and comprehensiveness of the news, so that re-disclosure of reported facts and reversals of the truth have become commonplace. This style of reporting causes substantial harm to the DPR. In addition, misguided media reports have led some patients to hold the belief that doctors conspire to provide unnecessary examinations and treatments to earn more money. Such patients habitually treat doctors oppositionally rather than cooperatively, and are typically resistant to prescribed examinations. For these patients, there is no way for doctors to establish a good DPR, especially in less than 15 minutes in the clinic, even if the doctor has perfect communication skills. Unfortunately, the number of patients with these beliefs is not inconsiderable. In addition, the lack of supervision in the “We media” era can also negatively affect the DPR. Due to the ease of access and understanding, influential bloggers and vloggers have become mainstream sources of medical information for non-professionals. However, the quality of information from these sources is mixed, and the printer at the convenience store in reality can even become a “virology expert” on the Internet. When patients find that their doctor’s diagnosis is different from what they have “self-taught” from the websites, they may question and distrust the doctor, potentially hindering the doctor’s normal medical work.

With the development and widespread use of electronic medical records (EMR), the entire daily workflow for doctors has been changed, which poses controversial impacts to the DPR and warrants specific discussion. An increasing number of studies have demonstrated that consultation length is positively correlated with a higher level of patients’ trust and better DPR (4), however, EMR documentation dilutes face-to-face time with patients. A previous study confirmed that face-to-face time between doctors and patients decreased from 55% to 27% and time spent on EMR and desk work increased from 15% to 50% for doctors in 2016 compared with 2005 (5,6). This means that in a 15-minute outpatient clinic, doctors spend an average of 7 minutes on EMR and only 4 minutes on face-to-face consultation. Thus, some individuals hold the belief that EMR has a negative impact on the DPR. However, there are also benefits of EMR, if used properly. For trauma patients, showing X-rays through EMR was found to promote patients’ understanding of their disease and increase communication efficacy (7).

The DPR plays an essential role in disease management and has been reported to correlate with symptom relief and better clinical prognosis (8). The DPR pattern has changed over the last several decades, shifting from a disease-oriented and asymmetrical doctor-centered pattern to a patient-centered pattern, focusing more on patient autonomy (9). In the patient-centered DPR, shared decision-making is advocated for, and patients are encouraged to participate in their own medical decisions after understanding the options, benefits, and potential harms (10). The DPR in China is unique; instead of being treated as individuals, patients prefer to be treated as a family unit and favor a doctor-family-patient communication pattern in which family members co-participate in decision-making.

When faced with disease, doctors and patients constitute a community of fate. Doctors often stand bravely between patients and “death”, sharing the risk and guarding their patients’ lives. Mutual trust and a harmonious relationship between doctors and patients are important prerequisites for effective treatment. Thus, the status of the DPR in China needs to be improved, and developing approaches for rebuilding the DPR in China represents an important social challenge. First of all, reform of the medical system and optimization of hospital management are imminent. Being a doctor is an occupation, but it is also a noble undertaking with substantial personal value compared with other jobs. Healing patients and protecting lives has direct value, and is also the reason many people choose to become doctors in the first place. However, in the current hospital management system, the measure of a good doctor is not directly related to their clinical performance. Moreover, most doctors’ salaries do not match the intensity of their work. Second, the media should take responsibility rather than create conflicts or exacerbate dissatisfaction. Under the influence of current public opinion, it seems impossible for doctors to be treated as ordinary people, either being considered “heroes” to be glorified, or “deserters” to be scorned. During the COVID-19 pandemic, the media reported that some doctors were working with high fevers, which became an invisible moral yoke for all the doctors, as if it was shameful for them to take sick leave or stay home from work with illness. Doctors are ordinary people who also get sick, have families, and need to earn money to live. Many doctors have faced scenarios in which they have to care for unfamiliar patients while being unable to take care of their own sick parents or children, and the guilt to their families can torment them as children or parents themselves. When reporting medical-related news, media outlets could invite medical professionals to review articles in advance of publication to avoid basic errors. The media’s public platform for promoting and popularizing basic medical knowledge and improving public medical literacy could be conducive to building harmonious doctor-patient communities. Third, regarding the doctor’s perspective, doctors need to continue learning, update their knowledge, learn about new medications, and keep track of the latest techniques in their specialty. Doctors who can quickly and accurately make diagnoses and relieve patients’ discomfort will gain patients’ trust easily and build good relationships with them. The formation of multidisciplinary teams is also a promising approach, especially for treating tumors and other complicated diseases, requiring doctors from different disciplines to use their expertise to jointly discuss cases and ultimately propose the best treatment plan for patients. Intentionally increasing patient involvement in the medical process, paying attention to body language, and participating in communication courses can also positively contribute to building a good DPR. Maximizing technology-related advantages, practicing skills in digital communication, and learning how to interact with EMR and patients at the same time are also demands placed on doctors in the current era. Despite doctors’ efforts, fundamental and comprehensive laws should be implemented to protect health workers as well.

It is an important time to pay attention to DPR in China. The current DPR dilemma cannot be solved by the efforts of a single person or group. A united effort is required by society as a whole, including the medical system, medical policymakers, media, and patients, to improve the medical environment, address the current DPR dilemma, and achieve a more harmonious DPR.

Acknowledgments

We thank Benjamin Knight, MSc., from Liwen Bianji (Edanz) (www.liwenbianji.cn) for editing the English text of a draft of this manuscript.

Funding: This work was supported by grant from the National Natural Science Foundation of China (No. 81972698).

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Hepatobiliary Surgery and Nutrition. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://hbsn.amegroups.com/article/view/10.21037/hbsn-23-104/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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