Correspondence
Regulations subsequently followed in 2013. Furthermore, a national electronic organ allocation system was introduced, which has a medically derived allocation algorithm that helps to allocate the donor organs equitably. Concurrently, the entire structure of the new national transplantation infrastructure was established.2 These measures, led by former Vice Minister of Health Jiefu Huang, were welcomed by WHO, and generated substantial increases in donations. As of July 7, 2014, according to the China Organ Donation Administrative Centre, 1963 donations enabled 5388 patients to receive organs for transplantation. The Hangzhou Resolution illustrates the consensus and resolve for change among Chinese transplant professionals. 3 According to Jiefu Huang, the reliance on executed prisoners as an organ source is coming to an end soon.4 Many centres no longer use this organ source for all the right reasons, which western countries and the medical community have raised. We deem the new system to be founded on justice, equity, and national consensus. In this sense, this is truly the beginning of a new era for transplantation in China. The new system is still developing and will undergo many changes. It is only a beginning, not a celebratory finish. Much work is to be done and progress is to be made. In a populous nation, such as China, with a long history of civilisation and culture, continued criticisms and pressures without recognition of rapid positive changes can be detrimental to continued progress. We declare no competing interests. The opinions expressed here are the authors’ personal opinions.
*Qiquan Sun, Xinpu Gao, Dicken Shiu-Chung Ko, Xian Chang Li [email protected] Division of Renal Transplantation, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510530, China (QS); China Organ Donation Administrative Center, Beijing, China (XG); Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA (DS-CK); and Immunobiology and Transplantation Research, Houston Methodist Hospital, Texas Medical Center, Houston, TX, USA (XCL)
742
1
2
3
4
Sun Q, Gao X, Wang H, et al. A new era for organ transplantation in China. Lancet 2014, 383: 1971–72. Huang J, Wang H, Fan ST, et al. The national program for deceased organ donation in China. Transplantation 2013; 96: 5–9. Huang JF, Zheng SS, Liu YF, et al. China organ donation and transplantation update: the Hangzhou Resolution. Hepatobiliary Pancreat Dis Int 2014; 13: 122–24. Organ transplantation is moving towards the rule of law, organs from executed prisoners will be history (in Chinese). http://finance. ifeng.com/a/20140818/12944828_0.shtml (accessed Aug 18, 2014).
Evolution of the perception of the doctor’s role in China The doctor–patient relationship is often associated with mistrust or even conflict in China today.1–3 Over time, there have been major changes in the role of doctors and their perception by patients: from god, emperor, and father to neighbour and friend, to merchant, and in some patients’ minds even to greedy liar. This perception of doctors could be an important reason for doctor–patient conflict, and doctors should be aware of it. In ancient times, medicine was done through superstition, and medical practitioners were wielding various mystical powers which other human beings can only obey. As civilisation advances, medical knowledge and experience accumulate. According to a Chinese tradition, all Chinese are proud “children of Yan and Huang”, legendary founder of traditional Chinese medicine. The Chinese language also reveals the honour doctors once enjoyed. Chinese call doctors “Dai Fu” (which also means scholar-bureaucrats) and “Xian Sheng” (master); medicine is seen as protective and authoritive. After the enlightenment movement, in modern China, western medicine is widespread. In this modern culture, medical practitioners are considered equal to other citizens. Patients can easily get medical knowledge from media, such as the internet, and the mystery around medicine
is almost removed. Doctors are no longer on a high altar. And with market economics, in some patients’ eyes, doctors are seen as servants, merchants, or even greedy liars. Today we can witness all these different scenarios in medicine. Still many people see “Feng Shui” masters for health and fortune,4 but they also go to traditional Chinese medicine or western medicine doctors; this could to some extent be explained by the polytheistic Chinese culture. When the doctor’s self-perception and the patient’s expectation don’t match, discontent arises (for example, when the doctor acts like a father, but the patient expects a friendly neighbour, or when the doctor works like a businessman, but the patient expects a father-like figure). This mismatch between projection, expectation, and reality can be seen as reasons by the patients to be angry or violent. Moreover, a patient might have several images of his doctor. Doctors need to understand this aspect of the relationship and address their patient accordingly. We declare no competing interests.
Jinya Cao, *Jing Wei [email protected] Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China 1 2 3
4
Hesketh T, Wu D, Mao L, Ma N. Violence against doctors in China. BMJ 2012; 345: e5730. The Lancet. Violence against doctors: Why China? Why now? What next? Lancet 2014; 383: 1013. Jing W, Otten H, Sullivan L, et al. Improving the doctor–patient relationship in China: the role of balint groups. Int J Psychiatry Med 2013; 46: 417–27. Xinhuanet. Behind the “master”, why the power “sleeps”? (in Chinese). http://news.xinhuanet. com/comments/2013-07/31/c_116752885. htm (accessed July 31, 2013).
China needs to tackle the decline in medical school applicants We read The Lancet’s Editorial about violence against Chinese doctors with great interest.1 In the past 5 years, more than 30 Chinese doctors have www.thelancet.com Vol 384 August 30, 2014
Correspondence
We declare no competing interests.
Pengfei Yang, Qinghai Huang, *Jianmin Liu [email protected] Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China 1
2
3
4
The Lancet. Violence against doctors: Why China? Why now? What next? Lancet 2014; 383: 1013. Rauhala E. Why China’s doctors are getting beat up. March 7, 2014. http://time. com/15185/chinas-doctors-overworkedunderpaid-attacked/ (accessed Aug 18, 2014). Nanfang Daily. Nineteen more students recruited by Tsinghua University. Nanfang Daily, July 13, 2010 (in Chinese). http://epaper.nfdaily. cn/html/2010-07/13/content_6860460.htm (accessed Aug 18, 2014). Chinese Ministry of Education. Basic requirements of reexamination for the 2014 national graduate entrance examination candidates. China Higher-education Student Information (CHSI), March 18, 2014. http://yz.chsi.com.cn/kyzx/ kydt/201403/20140318/828601850.html (accessed Aug 20, 2014).
www.thelancet.com Vol 384 August 30, 2014
Multisite licence to practise medicine in China With the new multisite licence to practise medicine in China, doctors will be allowed to work at several medical institutions. The government hopes that with the implementation of this new policy, more patients will go to medium and small-sized medical institutions, privately operated hospitals, or different institutions at different treatment phases instead of large tertiary centres. This policy is an an important component of Chinese health-care reform—it was proposed in 2009, but it has not been fully implemented yet. According to the national health and family planning commission, by August, 2013, 41 000 doctors had effective registration of a multisite licence. However, 41 000 doctors out of 2 million licensed doctors in China is a very small proportion. There are several reasons to explain the very slow implementation. First, although a multisite licence to practise medicine has been encouraged, a doctor’s registration in another medical institution still needs to be ratified by his primary institution, in most cities.1 Because of the resources invested in doctors, this multisite licence can be seen as a loss for the original hospital. Second, medical equipment and resources are important and are often concentrated in large tertiary hospitals, which also have excellent skilled doctors. Third, most doctors in China are very busy, some can see up to 100 patients a day—an overwhelming workload;2 in these conditions, it is difficult to find time to go to other hospitals to practise. We hope that supporting laws and regulations could provide a legal basis and safeguard for doctors to give them more freedom and independence. Only then, will doctors be able to embrace the multisite licence to practise medicine without worries.
We declare no competing interests.
Kejia Hu, Zhenzhong Sun, *Yongjun Rui, Jingyi Mi, Sanjun Gu
Hero Images Inc./Hero Images Inc./Corbis
been killed by their patients, which is unprecedented worldwide. In addition to medical graduates quitting the profession because of increased violence, the number of Chinese medical school applicants has decreased greatly in recent years. A survey done by the Chinese medical doctor association showed that only 6·83% of doctors would advise their children to choose this career.2 Even in the best medical schools, only a few applicants reach the required score line (eg, only 4 for Peking Union Medical College, the lowest number since the advent of China’s college entrance examination, in Guangdong Province in 2010). 3 Meanwhile, the national admission score for a graduate student majoring in medicine has also declined for 3 consecutive years, according to the Chinese Ministry of Education.4 It is no longer the best students who go to medical school. This is a growing concern: who will be tomorrow’s doctors? A thorough health-care reform should be given high priority to restore the doctor–patient relationship and prevent a shortage of medical workers.
[email protected] Huashan Hospital Affiliated Fudan University, Shanghai, China (KH); and Wuxi Number 9 People’s Hospital Affiliated Soochow University, Wuxi Jiangsu 214062, China (ZS, YR, JM, SG) 1
2
China national health and family planning commission. Doctors’ multi-sited licensed practice needs a written consent of the original hospital (in Chinese). http://news.xinhuanet. com/politics/2014-01/27/c_119154806.htm (accessed March 30, 2014). The Lancet. Violence against doctors: Why China? Why now? What next? Lancet 2014; 383: 1013.
The crisis of Chinese medical journals With the aim of transforming China into a research superpower by 2020, major investments have been made in medical research, covering basic scientific research, translational research, and clinical research. As a main indicator for the assessment of Chinese medical research, the number of articles listed in the Science Citation Index (SCI) has increased rapidly in recent years. Behind the encouraging achievement of a general upward tendency of Chinese papers published in The Lancet, The New England Journal of Medicine, and The Journal of the American Medical Association between 2000 and 2012,1 Chinese medical journals are encountering an unprecedented crisis. Because of the profit-seeking aspect of some Chinese medical journals and the wide disparity in influence between most Chinese medical journals and foreign medical journals, international medical journals are preferred by Chinese medical researchers. Additionally, in China, an article published in a journal with a high impact factor is key for a bonus or a rapid promotion. This bias further exacerbates the gap between Chinese medical journals and foreign medical journals. Certainly, publishing papers in international medical journals strongly contributes to academic 743
Regulations subsequently followed in 2013. Furthermore, a national electronic organ allocation system was introduced, which has a medically derived allocation algorithm that helps to allocate the donor organs equitably. Concurrently, the entire structure of the new national transplantation infrastructure was established.2 These measures, led by former Vice Minister of Health Jiefu Huang, were welcomed by WHO, and generated substantial increases in donations. As of July 7, 2014, according to the China Organ Donation Administrative Centre, 1963 donations enabled 5388 patients to receive organs for transplantation. The Hangzhou Resolution illustrates the consensus and resolve for change among Chinese transplant professionals. 3 According to Jiefu Huang, the reliance on executed prisoners as an organ source is coming to an end soon.4 Many centres no longer use this organ source for all the right reasons, which western countries and the medical community have raised. We deem the new system to be founded on justice, equity, and national consensus. In this sense, this is truly the beginning of a new era for transplantation in China. The new system is still developing and will undergo many changes. It is only a beginning, not a celebratory finish. Much work is to be done and progress is to be made. In a populous nation, such as China, with a long history of civilisation and culture, continued criticisms and pressures without recognition of rapid positive changes can be detrimental to continued progress. We declare no competing interests. The opinions expressed here are the authors’ personal opinions.
*Qiquan Sun, Xinpu Gao, Dicken Shiu-Chung Ko, Xian Chang Li [email protected] Division of Renal Transplantation, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou 510530, China (QS); China Organ Donation Administrative Center, Beijing, China (XG); Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA (DS-CK); and Immunobiology and Transplantation Research, Houston Methodist Hospital, Texas Medical Center, Houston, TX, USA (XCL)
742
1
2
3
4
Sun Q, Gao X, Wang H, et al. A new era for organ transplantation in China. Lancet 2014, 383: 1971–72. Huang J, Wang H, Fan ST, et al. The national program for deceased organ donation in China. Transplantation 2013; 96: 5–9. Huang JF, Zheng SS, Liu YF, et al. China organ donation and transplantation update: the Hangzhou Resolution. Hepatobiliary Pancreat Dis Int 2014; 13: 122–24. Organ transplantation is moving towards the rule of law, organs from executed prisoners will be history (in Chinese). http://finance. ifeng.com/a/20140818/12944828_0.shtml (accessed Aug 18, 2014).
Evolution of the perception of the doctor’s role in China The doctor–patient relationship is often associated with mistrust or even conflict in China today.1–3 Over time, there have been major changes in the role of doctors and their perception by patients: from god, emperor, and father to neighbour and friend, to merchant, and in some patients’ minds even to greedy liar. This perception of doctors could be an important reason for doctor–patient conflict, and doctors should be aware of it. In ancient times, medicine was done through superstition, and medical practitioners were wielding various mystical powers which other human beings can only obey. As civilisation advances, medical knowledge and experience accumulate. According to a Chinese tradition, all Chinese are proud “children of Yan and Huang”, legendary founder of traditional Chinese medicine. The Chinese language also reveals the honour doctors once enjoyed. Chinese call doctors “Dai Fu” (which also means scholar-bureaucrats) and “Xian Sheng” (master); medicine is seen as protective and authoritive. After the enlightenment movement, in modern China, western medicine is widespread. In this modern culture, medical practitioners are considered equal to other citizens. Patients can easily get medical knowledge from media, such as the internet, and the mystery around medicine
is almost removed. Doctors are no longer on a high altar. And with market economics, in some patients’ eyes, doctors are seen as servants, merchants, or even greedy liars. Today we can witness all these different scenarios in medicine. Still many people see “Feng Shui” masters for health and fortune,4 but they also go to traditional Chinese medicine or western medicine doctors; this could to some extent be explained by the polytheistic Chinese culture. When the doctor’s self-perception and the patient’s expectation don’t match, discontent arises (for example, when the doctor acts like a father, but the patient expects a friendly neighbour, or when the doctor works like a businessman, but the patient expects a father-like figure). This mismatch between projection, expectation, and reality can be seen as reasons by the patients to be angry or violent. Moreover, a patient might have several images of his doctor. Doctors need to understand this aspect of the relationship and address their patient accordingly. We declare no competing interests.
Jinya Cao, *Jing Wei [email protected] Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing 100730, China 1 2 3
4
Hesketh T, Wu D, Mao L, Ma N. Violence against doctors in China. BMJ 2012; 345: e5730. The Lancet. Violence against doctors: Why China? Why now? What next? Lancet 2014; 383: 1013. Jing W, Otten H, Sullivan L, et al. Improving the doctor–patient relationship in China: the role of balint groups. Int J Psychiatry Med 2013; 46: 417–27. Xinhuanet. Behind the “master”, why the power “sleeps”? (in Chinese). http://news.xinhuanet. com/comments/2013-07/31/c_116752885. htm (accessed July 31, 2013).
China needs to tackle the decline in medical school applicants We read The Lancet’s Editorial about violence against Chinese doctors with great interest.1 In the past 5 years, more than 30 Chinese doctors have www.thelancet.com Vol 384 August 30, 2014
Correspondence
We declare no competing interests.
Pengfei Yang, Qinghai Huang, *Jianmin Liu [email protected] Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China 1
2
3
4
The Lancet. Violence against doctors: Why China? Why now? What next? Lancet 2014; 383: 1013. Rauhala E. Why China’s doctors are getting beat up. March 7, 2014. http://time. com/15185/chinas-doctors-overworkedunderpaid-attacked/ (accessed Aug 18, 2014). Nanfang Daily. Nineteen more students recruited by Tsinghua University. Nanfang Daily, July 13, 2010 (in Chinese). http://epaper.nfdaily. cn/html/2010-07/13/content_6860460.htm (accessed Aug 18, 2014). Chinese Ministry of Education. Basic requirements of reexamination for the 2014 national graduate entrance examination candidates. China Higher-education Student Information (CHSI), March 18, 2014. http://yz.chsi.com.cn/kyzx/ kydt/201403/20140318/828601850.html (accessed Aug 20, 2014).
www.thelancet.com Vol 384 August 30, 2014
Multisite licence to practise medicine in China With the new multisite licence to practise medicine in China, doctors will be allowed to work at several medical institutions. The government hopes that with the implementation of this new policy, more patients will go to medium and small-sized medical institutions, privately operated hospitals, or different institutions at different treatment phases instead of large tertiary centres. This policy is an an important component of Chinese health-care reform—it was proposed in 2009, but it has not been fully implemented yet. According to the national health and family planning commission, by August, 2013, 41 000 doctors had effective registration of a multisite licence. However, 41 000 doctors out of 2 million licensed doctors in China is a very small proportion. There are several reasons to explain the very slow implementation. First, although a multisite licence to practise medicine has been encouraged, a doctor’s registration in another medical institution still needs to be ratified by his primary institution, in most cities.1 Because of the resources invested in doctors, this multisite licence can be seen as a loss for the original hospital. Second, medical equipment and resources are important and are often concentrated in large tertiary hospitals, which also have excellent skilled doctors. Third, most doctors in China are very busy, some can see up to 100 patients a day—an overwhelming workload;2 in these conditions, it is difficult to find time to go to other hospitals to practise. We hope that supporting laws and regulations could provide a legal basis and safeguard for doctors to give them more freedom and independence. Only then, will doctors be able to embrace the multisite licence to practise medicine without worries.
We declare no competing interests.
Kejia Hu, Zhenzhong Sun, *Yongjun Rui, Jingyi Mi, Sanjun Gu
Hero Images Inc./Hero Images Inc./Corbis
been killed by their patients, which is unprecedented worldwide. In addition to medical graduates quitting the profession because of increased violence, the number of Chinese medical school applicants has decreased greatly in recent years. A survey done by the Chinese medical doctor association showed that only 6·83% of doctors would advise their children to choose this career.2 Even in the best medical schools, only a few applicants reach the required score line (eg, only 4 for Peking Union Medical College, the lowest number since the advent of China’s college entrance examination, in Guangdong Province in 2010). 3 Meanwhile, the national admission score for a graduate student majoring in medicine has also declined for 3 consecutive years, according to the Chinese Ministry of Education.4 It is no longer the best students who go to medical school. This is a growing concern: who will be tomorrow’s doctors? A thorough health-care reform should be given high priority to restore the doctor–patient relationship and prevent a shortage of medical workers.
[email protected] Huashan Hospital Affiliated Fudan University, Shanghai, China (KH); and Wuxi Number 9 People’s Hospital Affiliated Soochow University, Wuxi Jiangsu 214062, China (ZS, YR, JM, SG) 1
2
China national health and family planning commission. Doctors’ multi-sited licensed practice needs a written consent of the original hospital (in Chinese). http://news.xinhuanet. com/politics/2014-01/27/c_119154806.htm (accessed March 30, 2014). The Lancet. Violence against doctors: Why China? Why now? What next? Lancet 2014; 383: 1013.
The crisis of Chinese medical journals With the aim of transforming China into a research superpower by 2020, major investments have been made in medical research, covering basic scientific research, translational research, and clinical research. As a main indicator for the assessment of Chinese medical research, the number of articles listed in the Science Citation Index (SCI) has increased rapidly in recent years. Behind the encouraging achievement of a general upward tendency of Chinese papers published in The Lancet, The New England Journal of Medicine, and The Journal of the American Medical Association between 2000 and 2012,1 Chinese medical journals are encountering an unprecedented crisis. Because of the profit-seeking aspect of some Chinese medical journals and the wide disparity in influence between most Chinese medical journals and foreign medical journals, international medical journals are preferred by Chinese medical researchers. Additionally, in China, an article published in a journal with a high impact factor is key for a bonus or a rapid promotion. This bias further exacerbates the gap between Chinese medical journals and foreign medical journals. Certainly, publishing papers in international medical journals strongly contributes to academic 743
