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

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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).

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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

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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

Correspondence

communication, bypassing geographic boundaries and enhancing disciplinary development. However, in China, roughly 4 billion patient-visits annually are undertaken by grassroots medical staff,2 and Chinese medical journals are their main source of medical information. And worryingly, some unreliable and low-quality Chinese medical journals hinder medical skill improvement in these personnel. Hence, to improve the overall quality of Chinese medical journals, and to narrow the disparity between Chinese medical journals and international medical journals is not only beneficial for grassroots medical staff but also extremely important to improve the quality of health care in China. Rebuilding a scientific and reasonable assessment system for medical research would be an essential step for the Chinese Government. We declare no competing interests.

Jun-Song Yang, *Ding-Jun Hao [email protected] Department of Spinal Surgery, Hong-Hui Hospital, Medical College of Xi’an Jiaotong University, Xi’an 710054, China 1

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Tong D, Wang L, Jiang J. Publications from China in The Lancet, NEJM, and JAMA. Lancet 2013; 381: 1983. National Health and Family Planning Commission of China. China Health Statistics Yearbook 2013. http://www.nhfpc.gov.cn/ mohwsbwstjxxzx/s7967/201404/f3306223b 40e4f18a43cb68797942d2d.shtml (accessed May 24, 2014).

Violence against doctors in China Undoubtedly, the doctor–patient relationship has worsened in China.1 In the past two decades, there has been a lot of violence against doctors, with serious effects on the medical community and prospects for the future.2 To tackle medical disputes, a new initiative was launched on April 24, 2014, to establish that such attacks on doctors will bring severe punishment. The Supreme People’s Court, the Supreme 744

People’s Procuratorate, the Ministry of Public Security, the Ministry of Justice, and the National Health and Family Planning Commission jointly issued guidelines that aim to bring strong punishments for violence involving medical staff. 3 With the new guidelines, violence such as intentionally hurting or killing medical staff, or damaging public or private property in medical institutions will be punished. Any behaviours that can disrupt medical practice, such as insulting or threatening medical staff or illegally carrying weapons in a medical institution, will result in punishment. And extremely serious crimes shall be subject to the death penalty.3 We believe that this latest guideline can help restrain violence against doctors. However, punishment is not an end in itself. We need not only to strengthen punishment by law but also to solve the problem, taking measures to prevent and reduce medical malpractice. On the one hand, the government should optimise the allocation of medical resources, improve current social insurance systems, continue to rein back drug prices, protect patients’ rights, improve medical technology and the quality of service, and take effective measures to guide patients to use adequate channels for complaint. On the other hand, medical knowledge should be made available to the community to improve people’s understanding of the risks of medical practice. Chinese media should assume their social responsibility. With effective measures and prompt actions, we believe that we will be able to rebuild confidence between doctors and patients. We declare no competing interests.

Lin Zhao, Xin-Yu Zhang, Gao-Yuan Bai, *Yao-Gang Wang [email protected] School of Public Health, Tianjin Medical University, 300070 Tianjin, China

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The Lancet. Ending violence against doctors in China. Lancet 2012; 379: 1764. The Lancet. Which future for doctors in China? Lancet 2013; 382: 936. Xinhuanet. China to punish crimes in doctor-patient flare-ups. http://news. xinhuanet.com/english/ china/2014-04/24/c_133287654.htm (accessed April 25, 2014).

Violence against doctors in China is an important issue, previously covered in The Lancet.1–4 One reason to explain this issue is the inadequate mechanisms for handling patient’s complaints in China.3 We studied the process of regulation for handling patients’ complaints and noted some important systemic constraints. First, conflicts can arise from the discrepancies between the legal system for handling complaints and the processes used and solutions determined by the hospitals. The absence of unified laws or guidelines results in inconsistency and uncertainty about how to apply different regulations. Second, hospitals have the main responsibility for hand ling complaints, including compensation for medical injuries. Hospitals prefer to compensate patients to minimise problems and to keep their reputation; but this strategy can also induce some patients to complain even more. Third, patient complaints are generally not linked to improved quality of care. Most complaints are solved on a case-by-case basis, without sufficient concern for the improvement of health services overall. Finally, in some cases, inconvenience or unexpected medical injuries experienced by patients are due to the organisation of the health and social welfare systems rather than caused by doctors or hospitals. To a certain extent, doctors and hospitals have become easy scapegoats for broader problems in the stewardship of the health and social welfare systems in China. We declare no competing interests.

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The crisis of Chinese medical journals.

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