AME survey-003 A2: on the attractiveness of an medicine career in current China with a survey of 7,508 medical professionals and 443 non-medical professionals

“If the misery of the poor be caused not by the laws of nature, but by our institutions, great is our sin.”

Charles Darwin
[1809–1882]

“A doctor must work eighteen hours a day and seven days a week. If you cannot console yourself to this, get out of the profession.”

Martin Henry Fischer
[1879–1962, German-born American physician and author]

“Experiencing suffering is necessary to be a complete doctor.”

Georges Mathé
[1922–2010, French oncologist and immunologist]

Background

This is a follow-up study of AME survey-003 A1 on job satisfaction of doctors in China (1,2). The purpose of this study is to understand whether previous results can further be confirmed. In addition, this study also aims to look at the attractiveness of a career in medicine in the eye of non-medical professionals. Furthermore, a small scale study was conducted to understand the weekly working hours among doctors in hospitals in Beijing.

Materials and methods

Survey on medical doctors’ motivations in China

The first part of this survey was conducted during the period of September 10-23, 2015, and the results (dataset-1) have been reported (1,2). The second part of this survey (dataset-2) followed the same method as the first survey, and conducted on DXY platform (www.dxy.cn) during the period of October 26 to November 20, 2015. DXY users who did not attend survey in the first period were invited to answer the same questionnaire (Appendix 1), and a token bonus was awarded to the users who completed survey. The third part of the survey using the same questionnaire was carried out on Sojump platform (wenjuanxin, www.sojump.com) during the period October 28 to December 14, 2005 (dataset-3). This survey was promoted via e-mails and Wechat (https://wx.qq.com/) through personal contacts, friends, and colleagues with the aim to balance out the young age bias seen in dataset-1 and -2.

There were 3,564 and 1,587 participants in dataset-2 and dataset-3 respectively. For dataset-2, the geographical distribution of the voters is shown in Figure 1, and followed the same pattern as in dataset-1 (1). For dataset-3, the geographical distribution of the voters is shown in Figure 2. Zhejiang province had the highest number of voters (n=421), followed by Guangdong province (n=161) and Hebei province (n=123). The geographical distribution of the three surveys’ voters pooled is shown in Figure 3. The age distribution of the three surveys’ voters pooled is shown in Figure 4, with a mean age of 31 (SD: ±7) years for dataset-2 and 37 (SD: ±8) years for dataset-3. The distribution of participants’ specialties in dataset-1, -2, and -3 are shown in Figure 5 (1,2).

Figure 1 Geographic distribution of participants for dataset-2 (n=3,564). This distribution is similar to dataset-1 (1).

Figure 2 Geographic distributions of participants for dataset-3 (n=1,587). The participant distribution is heavily weighted by participants from Zhejiang Province (n=421), Guangdong Province (n=161), Hebei Province (n=123), Beijing (n=123), and Jiangsu Province (n=102).

Figure 3 Geographic distributions of participants for dataset-1, -2, & -3 (n=7,508).

Figure 4 The age distribution of the participants among dataset-1, 2, and -3. Participants of dataset-1, -2 are heavily weighted by years—20~30 groups.

Figure 5 Distribution of various specialist cluster of dataset-2, dataset-3, and dataset 1-3 pooled together. Dataset-3 is over-represented by diagnostics specialty. SC1, internal medicine cluster; SC2, surgical sciences cluster; SC3, unspecified clinical medicine cluster; SC4, traditional Chinese medicine (TCM) cluster; SC5, oncology cluster; SC6, diagnostics cluster; SC7, pediatrics cluster; SC8, anesthesiology cluster; SC9, basic science research and public health cluster; SC10, obstetrics and gynecology cluster; SC11, accident and emergency cluster; SC12, nursing cluster; SC13, ophthalmology cluster.

Survey on non-medical professionals’ attitude toward their children studying medicine.

An online survey was carried out during the period of November 15 to December 2015 to investigate non-medical profession parents’ attitude towards their children studying medicine (dataset-4). Survey was conducted on Sojump platform (wenjuanxin, www.sojump.com) and distributed by authors through colleagues, friends, and relatives, and the questionnaire-flow diagram is shown in Figure 6. The primary targeted participants were those who are not medical doctors themselves, but have relatives and friends being medical doctors, therefore they knew the life style of being a doctor in China. Zhejiang province had the highest number of participants (n=69), followed by Ningxia province (n=68). The mean age of participants was 40 (SD: ±8) years, and included 155 males and 288 females. The geographical distribution of the voters is shown in Figure 7.

Figure 6 Flowchart of survey on non-medical professionals’ attitude toward their children perusing studying medicine.

Figure 7 Geographic distributions of participants for dataset-4. The distribution is heavily weighted by participants from Zhejiang Province (n=69) and Ningxia Province (n=68).

Survey on the working hours of doctors in Beijing

A brief survey on doctors’ working hours was conducted using Sojump platform (www.sojump.com) during December 19th pm~21st am, 2015. This survey platform was closed at 1:00 pm Dec 21st 2015 to avoid potential abuse. The estimated working hours was suggested to be averaged over one year. It was further reminded that if working 10 hours/day and 6 days a week, the total weekly working hours would be 60 hours/week; and if working 12 hours/day and 7 days a week, the total weekly working hours would be 84 hours/week. Wechat messages (https://wx.qq.com/) were sent via personal contacts to individual doctors in Beijing with their specialties as diversified as possible. The main goal was to get an estimation of the weekly working hours of approximately 50~100 Beijing-based doctors.

Results

For dataset-2, the N/Y ratio (not regretted participants =1,858 vs. regretted participants =1,706) was 1.09 (P=0.011). For dataset-3, the N/Y ratio (no regret participants =839 vs. regretted participants ratio 748) was 1.12 (P=0.022). Pooling dataset-1, -2,-3 together, the number difference between not regretted participants and regretted participants was significant (3,908 vs. 3,600, P<0.001). For both dataset-2 and dataset-3, there was no significant difference in N/Y ratio between male participants and female participants (Figure 8).

Figure 8 A graphic comparison of job satisfaction of male medical professionals vs. female medical professionals in dataset-2, -3.

For dataset-2, there were 2,232 participants from class-IIIA hospitals (62.6%) with an N/Y ratio =1.20 (P<0.001), followed by class-IIIB &-IIIC hospitals (8.0%) with an N/Y ratio =0.87 (P=0.259), class-IIA, -IIB & -IIC hospitals (22.4%) with an N/Y ratio =0.86 (P=0.469), and lastly class-IA, -IB, & -IC clinics (7.0%) with a N/Y ratio =1.29 (P=0.043, Figure 9). A total of 2,186 participants were trainee doctors (61.3%) with N/Y ratio =1.30 (P<0.001), followed by lecturer-level attending specialists (26.6%, N/Y ratio =0.71, P<0.001), associate principle doctors (9.8%, N/Y ratio =0.99, P=0.57), and lastly principle doctors (2.2%, N/Y ratio =2.1, P=0.002, Figure 10). In dataset 3, 52.4% participants were from class-IIIA hospitals with N/Y ratio =1.16 (P=0.029), followed by class-IIIB & -IIIC hospitals (12.2%) with an N/Y ratio =0.98 (P=0.886), class-IIA, -IIB, & -IIC hospitals (27.0%) with an N/Y ratio =1.07, (P=0.469), and lastly class-IA, -IB & -IC clinics (8.4%) with a N/Y ratio =1.25 (P=0.193, Figure 9). Among participants of dataset-3, 27.8% were trainee doctors with N/Y ratio =0.87 (P=0.14), followed by lecturer-level attending specialists (40.3%, N/Y ratio =0.94, P=0.477), associate principle doctors (22.2%, N/Y ratio =1.5, P<0.001), and lastly principle doctors (9.6%, N/Y ratio =2.8, P<0.001, Figure 10).

Figure 9 A graphic presentation of job satisfaction of medical professionals working at different classes of hospitals. Class-IIIA hospitals are the highest tertiary hospitals and many of them are university teaching hospitals. Class-IA & IB hospitals refer to small township hospitals or clinics.

Figure 10 A graphic presentation of job satisfaction of medical professionals of different seniority grades. Trainee doctors include graduate students in clinical specialties.

The same as the previous study we grouped all specialties into 13 clusters (SC1-SC13, Appendix 2). A few specialties were grouped together as single cluster due to the nature of their duties and operations are similar, such as radiology and pathology, and additionally the subspecialties N/Y ratios were also similar according to initial separate assessment. The job satisfaction for each cluster of dataset-2; and the results of polling three dataset together are shown in Tables 1 and 2.

Table 1 The not-regretted voter vs. regretted voter (N/Y) ratios in different specialty clusters of dataset 2
Full table

Table 2 The not-regretted voter vs. regretted voter (N/Y) ratios in different specialty clusters (three datasets pooled together)
Full table

The N/Y ratio’s geographical distribution is shown in Tables 3 and 4, and Figure 11. Medical professionals in Yunnan and Gansu ranked consistently high in job satisfaction; despite they were not in the economically advanced regions in China. While Jiangsu and Zhejiang, two economically advanced provinces, had relatively higher negative response (lower N/Y ratio).

Table 3 The N/Y ratio (not-regretted voters vs. regretted voters ratio) in various provinces and regions from dataset-2 (n=3,564).
Full table

Table 4 The N/Y ratio of all voters (no regret participants vs. regretted participants ratio) in various provinces and regions from dataset 1+2+3 (n=7,508)
Full table

Figure 11 A graphic presentation of job satisfaction of medical professionals at individual provinces with three datasets pooled together. Color map represents the N/Y ratio with lighter color representing less extent of satisfaction. Note Tibet (XZ) has only three participants for this study.

In both dataset-2&3, with the respondents who gave answers to question-3 and said they regretted entered medical profession, a large portion replied they would like to be in medical profession if they could enter their preferred hospital classes and specialties (Figures 12 and 13). In dataset-2, 1,632 participants (45.8%) still replied being a doctor is a good choice comparing with some other professions (Figure 12). For the participants in different seniority levels, 655 (57.5%) of graduate students, 471 (45.0%) of trainee doctors, 308 (32.5%) lecturer-level specialist doctors, 152 (43.6%) of associate principle doctors, 46 (57.5%) of principle doctors replied being doctor is a good choice compared with some other professions. In dataset-3, 667 participants (42.0%) still replied being a doctor is a good choice comparing with other professions (Figure 13). For the participants in different seniority levels, 52 (53.1%) graduate students, 122 (35.6%) trainee doctors, 250 (39.1%) lecturer-level specialist doctors, 154 (43.6%) associate principle doctors, 89 (58.2%) principle doctors replied being doctor is a good choice compared with some other professions. These conflicting answers reflect that these respondents were not satisfied with their current personal circumstances, but still had a positive view on medical doctor as a profession in China. In addition, the trends with doctors of different grades concur with the trends shown Figure 10 and also the results in dataset-1 (1); reflecting lecturer-level specialist doctors are under more stress in some ways.

Figure 12 In dataset-2, with the respondents who gave answers to question-3 and said they regretted entered medical profession, a large portion replied they would like to be in medical profession if they could enter their preferred hospital class and specialty.

Figure 13 In dataset-3, with the respondents who gave answers to question-3 and said they regretted entered medical profession, a large portion replied they would like to be in medical profession if they could enter their preferred hospital class and specialty.

A total of 152 and 243 respondents had their child/children attending university or graduated from university in dataset-2 and dataset-3 respectively. Their studying subjects or professions are shown in Figure 14A-D. Pooling together datasets 1-3, a total of 508 respondents have their child/children attending university or graduated from university, 104 (20.5%) are pursuing a career in medicine. These data show medicine remained an attractive choice among doctors’ children, followed by economics & finance, and then computer sciences & electronic engineering.

Figure 14 (A-D) The studying subject or profession distribution of respondents’ children who had attended university or graduated.

For dataset-2 and -3, a total of 1,396 and 962 respondents have child/children and did not reach university age yet, among them 22.3% and 18.7% replied respectively that they would like their child/children to study medicine. For dataset-2, among the respondents who would like their child/children to study medicine, 195 (62.5%) preferred their child/children to enter first-line specialties such as cardiology and orthopedics, while 97 (31.1%) preferred their child/children to enter second-line specialties such as radiology, electrocardiography (ECG), or pathology etc.; while 10 (3.3%) specifically liked their child/children to study Chinese Traditional Medicine (CTM), 6 (1.9%) liked their child/children to study Dentistry. Four respondents replied it would be up to the interests of the child. For dataset 3, among the respondents who would like their child/ children to study medicine, 97 (53.9%) preferred their child/children to enter first-line specialties, while 56 (31.1%) preferred to enter second-line specialties, while 27 (15.0%) preferred other medicine subjects.

For dataset-4, 443 participants meet the survey requirement, i.e., they were not medical profession (NMP) and had children, and including 288 (64.3%) females and 155 (35.7%) males, with mean age of 40.1±7.7 yrs. A total of 348 NMP respondents (78.6%) had at least one friend or one relative is a doctor. Among them 107 had child attended or graduated from university, 12 (11.2%) of them studied medicine. The children of 321 NMP respondents did not reach university age, and these parents’ attitude is show in Figure 15A-C. The data showed overall students are well supported by their parents to study medicine, among NMPs’ children who are attending university or have graduated, 9.8% (12/122) are pursuing a career in medicine. Our data also showed the NMP respondents who have at least one friend or one relative being a doctor were more likely to have their children pursuing a career in medicine.

Figure 15 Attitude of 321 non-medical professionals toward their children to study medicine. (A) Flow diagram of the questionnaire; (B) upper pie, the replies of non-medical professionals who have at least one doctor friend/relative on whether they would support their children to study medicine. lower pie: the replies of non-medical professionals who have no doctor friend/relative on whether they would support their children to study medicine; (C) left pie, 110 parents’ children did not study medicine in university. If given free choice again, 60 parents would support their children to study medicine, while 50 parents would not support. Right: the data in left pie is further broken down into those have friend or relative being a doctor, and those have no friend or relative being a doctor.

When asked the estimated working hours per week, 60 doctors gave answers including 14 trainee doctors, 25 lecturer-level specialists, 15 associate principle doctors, and 6 principle doctors. 54 (90%) were from class-IIIA hospitals, 3 from class-IIIB hospitals, and class-IIIC, IIA, and IB had one participant each. Trainees, lecturer-level specialists, associate principle doctors, principle doctors gave an estimation of 49.9±9.4, 56.8±8.5, 58.5±11.4 and 54.2±6.6 hrs/week, respectively (Figure 16).

Figure 16 Estimated weekly working hours among 60 Beijing based doctors, including 14 trainees, 25 lecturer-level specialists, 15 associate principle doctors, and 6 principle doctors.

In dataset-2 and dataset-3, those favor or against China to open up medical market to let qualified foreign medical organizations to participate in fair competition in China’s market; and those favor or against government to support regulated private hospitals are shown in Figure 17. Despite the demographic differences between participants of dataset-2 and dataset-3, the percentages of favor or against the changes were remarkably similar, with the participants in dataset-2, being younger, slightly more in favor of changes than the participants in dataset-3.

Figure 17 The attitude of participants favor or against China to open up medical market to let qualified foreign medical organizations to participate in fair competition in China’s market (A&B); and participants favor or against government to support regulated private hospitals (C&D) (dataset-2 & -3).

The questionnaire item-18 was to let participants to comment on the current healthcare system in China. Participants enthusiastically expressed their views. After removing the duplicative comments, 1,105 comments are presented on line at http://blog.sciencenet.cn/blog-3000837-952956.html (in Chinese). In addition, 50 selected comments have been translated into English and presented in Appendix 3.

Discussion

Reliability of the survey results

This survey is the largest on the motivation of medical professionals in China, and a number of consistent patterns were observed from three datasets (1,2). However, a few limitations remain. The first is the great under-representation of doctors working in rural clinics, primary care and class-I hospitals, and the under-representation of senior doctors. Both primary care doctors and senior doctors tended to demonstrate higher job satisfaction (1,3). Another limitation is the over-representation of the age group between 20~30 yrs in dataset-1 and dataset-2. These were due to the web-based nature of the surveys. Dataset-3 had more matured participants, on the other hand its limitations include the profession clusters are dominated by diagnostics [67%], and voters from Zhejiang province counted for 26.5%. The survey on NMPs’ attitude toward their children studying medicine and the working hours of Chinese doctors remain preliminary. Both studies had limited number of participants, and not well balanced in geographical distribution. However, Ningxia province and Zhejiang province are geographically and economically rather different.

We tend to suspect that the participants might have slightly over-estimated their working hours, and quite likely have under-estimated their income in relative term compared with other professions in China. One example is the great under-estimation of working hours of Korean doctors compared with the working hours of Chinese doctors (see more discussion below). These subjectivity and psychological factors have been previously discussed (1,2,4,5). This study further demonstrates that the results of such kinds of survey should be interpreted with great caution (4). The job satisfaction rate might have been under-estimated in this study due to reasons stated above. That some participants replied that they regretted joining medical profession was more likely to express dissatisfaction with their current personal situation, instead of really regretted they joined the medical profession overall.

The relationship among doctors’ professional grade, specialty, hospital class, geographical regions, and job satisfaction

Understandably this survey consistently showed principle doctors had higher job satisfaction, with N/Y ratio of 2.83 with dataset-3. Doctors at class-I clinics & hospitals, and doctors at class-IIIA hospitals tended to have better job satisfaction than doctors in hospitals in other classes. The reasons have been explained our previous papers (1,2). The results suggest measures should be taken to motivate doctors in class-II and class-IIIB/C hospitals. This survey consistently showed the doctors at economically more developed eastern coast regions, such as Zhejiang province and Jiangsu province, did not necessarily have higher job satisfaction than economically less developed provinces. In fact, Yunnan and Gansu provinces consistently ranked high in doctors’ job satisfaction. This might be related to the relative purchasing power of the salary and also probably the more relaxed life style in these provinces. Consistent with our report in dataset-1 (1), this paper shows specialties with less stressful workload had the higher job satisfaction. Public health and basic science research specialty cluster (SC9) staff do not directly face the patients. It is generally accepted that disputes between patients and doctors are more likely to occur with surgeons than anesthesiologists, while anesthesiologists (SC8) can enjoy the job security and relative good income by working in hospitals. Oncologists (SC5) are less likely to face disputes and violence from patients because the patients and relatives tend not to have an unreasonably high expectation for the treatment outcome. Doctors in diagnostics cluster (SC6) tend to have less face-to-face contact with patients. Traditional Chinese Medicine physicians mostly deal with chronic but not severe diseases. As having been well documented, this study further confirms accident and emergency physicians (SC11), nurses (SC12), and pediatricians (SC7) have less job satisfaction.

International comparison of doctor’s weekly working hours

For doctors’ working hours, hereby we choose the reported data of doctors in South Korea, Japan, Hong Kong, India, and USA for comparison. In a 2012 survey carried out by the S. Korean Surgical Society (5) (Figure 18), it was reported that more than 90% of the surgical residents surveyed worked more than 80 hours per week [=(11.3 hours/day)*(7 days a week)]. Furthermore, 60.6% percent of the residents worked more than 100 hours per week [=(14.3 hours/day)*(7 days a week)]. Almost half of the surgical residents surveyed (48.5%) reported working night shifts more than 4 days a week. 17.2% of residents had 6 or 7 night shifts per week. In addition, based on one survey reported in 2008, over 40% of surgery residents worked more than 18 hours per day (6,7). In a 2012 survey (8), 53% of Korean specialist surgeons worked more than 60 hr a week [=(10 hours/day)*(=6 days a week)], 26% of surgeons worked more than 80 hours a week, and strikingly, 14% of surgeons worked more than 100 hours a week. A personal contact of one author, a radiologist at a university hospital in Seoul, informed that he usually works 71 hours a week as standard (Monday to Friday: 7:00 am to 21:30 pm, Sat: 8:00 am to 14:00 pm).

Figure 18 Distribution of working hours of surgical residents in Korea [a year-2012 survey, reproduced from (5)].

According to 2006 statistics of Ministry of health, labor and welfare of Japan, the mean working time of hospital doctors was 63.3 hours at the main hospital and additional 7.3 hours at other hospitals per week [total: 70.6 hours/week (9)]. Young doctors may work up to 80 hours a week (Figure 19). Some Japanese doctors work more than 100 hours a week and see as many as 100 patients a day (10). In Hong Kong, in a 2011 poll of 711 public sector doctors, they work an average of 65.6 hours per week, with 3% work more than 100 hours per week, and 12% work more than 80 hours a week (11). While in India, taking the example of a typical work week of an anesthesia resident includes three duties and three regular days of work. A regular day of work includes operation theatre duty, intensive care unit/cardiac care unit/neonatal intensive care unit/pediatric intensive care unit duty, teaching seminars, thesis work, and running outpatient department services. While a duty day means 24 straight hours of emergency/casualty posting and operation theatre service and responding to cardio pulmonary resuscitation calls. This “duty” day then blends into the next “regular” work day without a break. This duty roster continues to operate for three years’ duration of residency (12).

Figure 19 A graphic comparison of working hours between doctors in Beijing (yr-2015 data) and doctors in Japan [year-2006 data, modified from (9)].

On July 1, 2003, the Accreditation Council on Graduate Medical Education (ACGME) of USA implemented the guidelines for all residency training programs limiting the time of in-house duty to 80 hours per week. In a pre-implementation survey of orthopaedic residents in July 2003, 49% of responding house staff reported working 80 to 100 hours per week, and 40% worked 60 to 80 hours on a weekly basis before the new rules (13). One year after implementation of the ACGME guidelines 13% orthopaedic residents were on duty more than 80 hours on average per week. However, 33% reported they worked, at times, more than 80 hours per week, but intentionally under-reported their hours (13). Across all specialties and in recent years it was reported that non-resident physicians in USA works on average 51.0 hours/week in 2006-2008 (14). The doctors USA who work the longest hours are cardiologists, who reported working 60 hours per week [year-2013 data (15)].

The working hours of non-resident physicians in Beijing, also primarily in class-IIIA hospital (90%), were self-reported to be 56.98 hours/week; and this is likely to represent a high end of working hours for Chinese doctors. These data seem to suggest Chinese doctors work no more hours than doctors in USA, but trainee doctors in China work fewer hours than their counterparts in Korea, Japan, and India. Residential training of clinical skills is THE most important period of medical education. Clinical skill training is also the most difficult one to tackle in China [Appendix 3 (16)]. Another significant obstacle is Chinese students’ less familiarity with English literature, which creates another hurdle for trainee doctors to learn the most recent evidences (17).

International comparison of remunerations

The income of doctors in China is difficult to accurately quantify, as the remunerations include basic salary, bonus, and other benefits. Internationally, approximately medical doctors earn 50% more than peers with similar qualifications and experiences over the life time, but medical doctors need to work longer time (15,18-20). Note PhD students and post-doctoral fellows, which are equivalent to trainee doctors, are also poorly paid. Japanese doctors are known for their long working hours and relative low salary [around 125,000 USD dollars a year at mid-career (10)]. The case in USA is a special case where the students have to pay expensive tuition fee for medical school. A typical doctor doesn’t earn a full-time salary until 9–10 years after the typical college graduate starts making money. In addition, if a physician is working individually in private practice, he/she needs to have his/her own malpractice insurance paid by him/herself, and this malpractice insurance premiums generally range 40,000–80,000 USD yearly depending on the location and the type of practice. Also if that individual physician was previously sued, the premium goes up significantly.

It is highly feasible that the rough rule that medical doctors earn 50% more than peers with similar qualifications and experiences over the life time can be satisfied, or has been satisfied in some cases, in China. Cuba’s experience is that the State trains lots of doctors. The doctor-to-patient ratio in Cuba is three times of that in USA (21,22). The authors expect the doctors in Cuba could work much less hours than colleagues in USA, Japan, and Korea, and in return they earn similar salary as state employees of other professions. This would be a more humane and workable alternative approach.

International comparison of patient vs. doctor relationship

The international comparison of patient vs. doctor relationship is beyond the scope of this study. However, since this issue is highly concerned among Chinese doctors (23). We try to put forward some discussions. Patient and visitor violence is a complex occupational hazard for health care staff working in general hospitals, as we described previously (2). Globally, healthcare workers are one of the most likely groups to experience workplace aggression (24). In a systematic review of the literature (25), Hahn et al. noted that about half of health care staff reported having experienced patient violence while almost all nurses reported having been exposed to patient and visitor violence. A 2005 study on Australian general practitioners found that 63.7% of those sampled had experienced violence at work (26). A 2011 cross-sectional survey by Hahn et al. showed that 50% of all staff (n=2,495) in a Swiss University Hospital had experienced patient and visitor violence over the previous 12 months, with 11% having experienced it in the previous week (27). In a small sample Lepping et al. reported in North Wales 83% of staff (n=131/157) reported being verbally abused over the previous 4 weeks. In total, 55% (n=79/144) reported being threatened and 68% (n=99/146) reported actual physical assault. Of those assaulted, 56% sustained an injury and three needed medical assessment and/or treatment (28). Moreover, One 2009 report showed that the prevalence of violence toward physicians in emergency departments in Morocco was 70% in the previous 15 days (29). Additionally, a Korean study shows the medical sues against doctors or hospitals have been increasingly in the recent decade (Figure 20) (30).

Figure 20 The medical sues against doctors or hospitals have been increasingly in recent decade in S. Korea (30).

In China, the severity of medical disputes has been increasing significantly over the past two decades, due to a lack of trust between physicians and patients and an imperfect legal system that provides weak safeguards of the rights and interests of both healthcare professionals and patients (23). However, because reported studies from different countries employed different methodologies and definitions, international comparison is difficult. While medical disputes happen in any countries, we expect it is more like to occur when patients feel the arbitration force (or law enforcement) would not settle the disputes fairly. We expect it will be very useful if an independent organization will be set-up to deal with these issues transparently, being fair to parents and healthcare staff. Various data can be stored in database, risk factors scientifically analyzed so to prevent future occurrence as much as possible. Since medical errors in a sense is inevitable, the matter of professional liability insurance can be purchased by the hospital for doctors, the same as in many other countries.

In a 1984 recent report from the Institute of Medicine, it was estimated approximately 98,000 patients die each year as a result of a medical error in USA (31). A more recent analysis suggests a much higher number (32). Similar data is not available for China. However, patients, doctors, and hospitals have to accept medical error is part of life in healthcare system. Regretful events such as misdiagnosis and surgical complication do happen occasionally (and also inevitably). However, these events have to be within the limit of certain accepted percentage. When the frequency of errors occurs above some recognised thresholds, the involved doctor may need to be re-trained in some areas.

Patient satisfaction towards doctors was not investigated in this study. Patient satisfaction had a major impact on shaping the public healthcare policy in Western countries. Since 1998, France has been using patient satisfaction as a mandatory index to evaluate hospitals (33). In the UK, the National Health Service also included patient satisfaction into medical contracts, and introduced policies to allow the public to monitor and improve the quality of health-care services (34). As the increase of expenditure on healthcare in China is faster than GDP increase (Figure 21), more attention and research should be spent on improving patient satisfaction in China (35).

Figure 21 Year annual growth rate of GDP (in PPP) and healthcare expenditure (in % PPP GDP) of China Mainland. Available online: http://data.worldbank.org/. GDP, Gross Domestic Product; PPP, purchasing power parity.

International of comparison of job satisfactions and the attractiveness of medical profession

This further study confirmed the conclusion of our last report (1,2). The morale and motivation of medical doctors in China are likely to be similar to other continuously evolving societies (2). Medicine remains one of the top choices for doctors’ children’s career. It is also recommended by non-medical professionals. Additionally, in a small 2016 survey a similar question was posted to DXY users, asking ‘will you choose a career in medicine if you were able to do it all over again’ (36). Thirteen DXY users replied, among them 6 said they would still like to a doctor; 5 said they would not like to a doctor; one said he/she would not but he/she will try best be to a good doctor since already chosen this profession; while one said he/she wanted to do something more important and fundamental than simply being a doctor (36). This small newest survey further confirms our results. In the meantime, that doctor parents’ children choose to study medicine could be affected by the fact that these doctor parents might feel they knew this walk of life, and had right connections to secure better jobs for their children.

In China the university specialty selection for secondary school graduates is heavily influence by parents, relatives, and teachers; the decision is rarely solely made by the secondary school graduates themselves. It is thus not surprising that a portion of medical doctors would indeed prefer to pursue another career and they regretted joined medical profession. This should be solved by more consultations when secondary school graduates select university study subject; and more flexibility for junior year university students to switch subjects.

International of comparison of job satisfactions has been partially addressed in our last papers (1,2). Additional examples include according to a 2013 survey by NerdWallet, in USA most doctors were reported to be dissatisfied with the job, and less than half said they would choose a career in medicine if they were able to do it all over again (13). In Kang et al.’s recent 2012 study on surgical residents in S. Korea, 49.5% of the surveyed replied that they would not become a physician if they were to make the choice again (5). With the same group’s 2012 survey on specialist surgeons, 50.7% said that they would not become a surgeon again, and 84.4% felt that they were not able to balance their personal life and work, and 82.5% said that they would not recommend their career to their children (8). The subjectivity of these answers remains unknown to the current authors.

Implication of this study

Medicine remains an attractive profession in China. The overall morale of the medical profession in China remains healthy. It looks the working hours of Chinese doctors is no more than colleagues in the neighboring countries such as Korea and Japan. As some noted by some participants, because medicine is attractive, to train better doctors, a higher threshold for medical school enrollment can be implemented.

The majority of participants in this survey support additional expansion of well regulated private hospitals and foreign hospitals to enter Chinese market. This can be further considered by Chinese government. The slight difference between dataset-2 and dataset-3 may suggest that younger generation doctors are more open to changes. Patient satisfaction would be improved by developing nonpublic hospitals that increase the health-care supply in specific markets. Nevertheless, care should be taken as the competition among public and nonpublic hospitals in the medical market is a “double-edged sword” [(35,37) Appendix 3].

In addition to recruit highly motivated medical students, much more attentions should be paid to the most difficult part, i.e., clinical skill training.

China should be prepared to learn from different sources, including Japan and Cuba, instead of over-borrowing the costly American system.

A healthcare system should be designed so that while hard-working qualified doctors are well paid, but doctors should not be allowed to become VERY rich due to their clinical skills. If doctors can profit hugely to their clinical skills, then by nature they will be reluctant to disseminate their clinical skills, and younger generation of doctors will have less chance to learn and mature, particularly in the field of surgical sciences. This will lead to undesirable consequence for patients.

Acknowledgements

The authors thank every participant in this study, particularly for their valuable comments. The authors are grateful for the supports by the DXY, and AME publishing Company, particularly the helps provided by Dr. Dao-Yuan Wang, Miss Si-Hua Elva Zheng, Miss Dan Ann Yang, Miss Mei May Li of AME Publishing Company; and Miss Yin-Nan Xu of DXY Company.

The authors thank the assistance of following colleagues during the course of the study and manuscript preparation [Dr. Yong Wang, the Cancer Hospital and Institute, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China; Dr. Dawei Yang, the Beijing Friendship Hospital, Capital University of Medical Sciences, Beijing, China; Dr. Yong Eun Chung, Yonsei University Health System, Seoul, S. Korea; Dr. Akira Yamada, Shinshu University Hospital, Nagano, Japan; Dr. Tomohisa Okada, Kyoto University Hospital, Kyoto, Japan; Dr. A. Cahid Civelek, National Institutes of Health (NIH) Clinical Center, Bethesda, MD, USA; Dr. Alexander Guimaraes, Oregon Health Sciences University, Portland, USA; Dr. Richa Arora, Nizam’s Institute of Medical Sciences, Hyderabad, India; Dr. Ran Mo, Nanjing University School of Medicine, Nanjing, China; Dr. Jiang Lin, Zhongshan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Dr. Yong-Ming He, the First Affiliated Hospital of Soochow University, Suzhou, China].

Footnote

(I) The primary aim of this study was to survey clinical doctors working in hospital. A small number of nurses and public health and medical research staff also participated in this survey, thereby also included in this analysis.

(II) During the design the questionnaire, it was generously assumed that each parent has one child due to the ‘one child policy’ existed in China.

(III) For the data interpretation, subjective components were introduced as the authors saw appropriate. In case of errors, author Wang YX takes sole responsibility.

Conflicts of Interest: This study was partially supported by the DXY Company and AME Publishing Company. The DXY Company and AME Publishing Company have no influence on the study resign and interpretation of the results.

Appendix 1

Appendix 2

Specialty cluster details (dataset-2)

SC1: internal medicine cluster participants

Cardiology =249; neurology =168; internal medicine (unspecified) =135; respiratory medicine =119; gastroenterology =114; endocrinology =127; nephrology =77; intensive care =75; dematology =32; psychiatry =25; hematology =49; medicine-infective disease =36; physical therapy =4; geriatrics & gerontology =3; medicine-tuberculosis =2; rheumatology =18; cerebrovascular disease =2.

SC2: surgical sciences participants

Orthopedics =203; general surgery (abdominal) =201; surgery (unspecificied) =25; ENT surgery =45; urology =57; neurosurgery =66; dental surgery =49; cardiothoracic surgery =41; burn surgery =5; plastic surgery and micro-surgery =10; organ transplatation surgery =3.

SC3: unspecified clinical medicine cluster participants

Clinical medicine unspecified =393.

SC4: traditional Chinese medicine (TCM) participants

TCM =278.

SC5: oncology cluster

Oncology =137.

SC6: diagnostics cluster participants

Radiology =63; clinical diagnostics (unspecified) =28; lab medicine =37.

SC7: pediatrics cluster participants

Pediatrics =119.

SC8: anesthesiology cluster participants

Anesthesiology =93.

SC9: basic science research and public health cluster participants

Basic science research =199; public health =39.

SC10: obstetrics and gynecology cluster participants

Obstetrics and gynecology =101.

SC11: accident and emergency cluster participants

Accident and emergency =44.

SC12: nursing cluster participants

Nurse =43.

SC13: ophthalmology cluster participants:

Ophthalmology =50.

Appendix 3

Selected comments and suggestions from participants

1. The ‘standardized training’ (guī-péi) is useless. The guī-péi trainees are only used as interns and have little chance to learn clinical skills, particularly surgical skills. The system should not be so irresponsible. Three years’ guī-péi time is simply wasted.

2. The quality of doctors at small hospitals and primary care clinics should be improved, so to ease the burden on tertiary hospitals. Favorable policy should be promoted that patients with mild illness will like to be treated in small hospitals and primary care clinics.

3. Currently doctors have to spend far too much time on paper works.

4. Please give time back to doctors, so that doctors have the time to do see patients, instead of doing so call ‘research’, particularly ‘basic research’.

5. Hope patients will have more understanding for doctors and their difficulties; in the meantime, doctors should try their best to look after patients, and have high moral standard.

6. Continuing education should be strengthened for doctors both in public hospitals and in private hospitals.

7. If there will be any new policies in the future, please do try to hear from what doctors want to say, particularly what the vast majority of grassroots doctors like to say.

8. The threshold to become a doctor should be raised to ensure the quality of them.

9. Those who want to make lots of money will not be able to become a good doctor.

10. The various supporting units of the hospitals should provide service to the frontline doctors, instead of creating hurdle for doctors.

11. Hospitals should demonstrate their public warfare aspects, now most of the hospitals are seeking profits. The burden on ordinary peoples is heavy.

12. Firstly, nowadays all walks of life require hardworking, doctors should not complain too much. Secondly, the high workload is due to that many mildly sick patients visit big class-III hospitals. Much resource is wasted because there is no adequate allocation of patients with different severities of diseases.

13. Structural changes of the health system should not be simplistically templated. These measures should be thoroughly thought about before stepwise careful implementation. Otherwise, the dream of a few generations will be sacrificed.

14. Personally I believe the healthcare issue remains a challenge globally. Many diseases cannot be well treated. A person being ill is a heavy burden for the family as well as for the nation. I hope the state can offer free healthcare to every citizens.

15. China should not simplistically follow the Western systems without paying attention to her unique social environment.

16. It is not that China does not have enough hospitals, rather, it is due to the government did not handle the issues very well.

17. The circumstance and income of doctors are related to the level of economic development of the country. They are also related to the organizational structure of healthcare.

18. There is a big difference of income among doctors of different grades. There is an even bigger difference among permanent staff and temporal staff.

19. There is a severe problem of over-examination and over-treatment. To avoid responsibility, over-examination is very common.

20. The large hospitals in cities should have favorable measurements for migrant workers from the rural countryside.

21. To make sure grassroots people can afford to see doctors.

22. Every walk of life has its difficulties. Try to find the areas where interest yourself, and then you will realise it is good to be a doctor.

23. It is really difficult to seek proper treatment for ordinary people.

24. It is really too expensive for patients to seek treatment.

25. While it is acceptable to have busy schedule during working days, vacations and holidays should be protected.

26. The hospitals should be managed by professional management team, and regularly audited. The social warfare function of hospitals should be realised.

27. Young doctors lack sufficient clinical experience, while no senior doctors are around to coach them.

28. Currently, the healthcare resource in China is not as bad as some people think. The high workload of some doctors is due to the uneven distribution of healthcare resources. There are few patients in township small hospitals and primary care clinics; and these centers also lack skilled staff and advanced instruments compared with bigger hospitals. This leads to a vicious circle that the medical standard in township small hospitals and primary care clinics could not be improved; in the meantime the resources there are wasted. Skilled staff should be encouraged to work in township small hospitals and primary care clinics, their remuneration should be much raised if they are willing to work there. Thus step-by-step the manpower skills and instruments can be advanced in township small hospitals and primary care clinics; and then patients will be willing to seek treatment locally instead of always going to big hospitals in major cities.

29. On one hand the work load of doctors is very high; on the other hand, hospitals are scrabbling for patients because the number of patients a hospital sees is related to the income of the hospitals. It is all right if hospitals are considered to be commercial ventures, and thus please offer us decent salary; it is also all right if hospitals are considered to be of government institutions, and then please give us time and the security.

30. In this competitive world, only parents can be relied on, every walk of life requires hard work.

31. The administrative classification and professional grading of hospitals should be abolished. The current class-III hospitals should be classified only into 1) comprehensive hospitals and 2) specialized hospitals. Much supports should be given into small township hospitals and primary care clinics. Rural doctor training should be improved, and incentives should be implemented to retain rural doctors. Various insurance policies should participate in efficient competition, but should not interfere with clinical treatment.

32. Where the departments or doctors have the responsibility of doing research, the hospital should guarantee the trustability of their scientific publications.

33. The medical college education system in China should be changed. There should be more clinical skill learning while less theoretical examinations

34. There are some malicious competitions among hospitals such as some rural doctors are contracted to refer patients to certain hospitals, and thus these rural doctors get kickback money. These behaviors should be strictly controlled.

35. Hospitals should be divided into two types, i.e., public hospitals, and private hospitals. Public hospitals serve the poor, even those patients who do not have money, and the government foots the bill. Private hospitals may seek profit, where the rich can enjoy the service of higher quality.

36. Nowadays the managements of hospitals are all seeking economic performance to show they are doing a good job to their superiors.

37. The mechanism of doctors’ professional grading and promotion should be much improved.

38. Make sure doctors can concentrate on treating patients, instead of spending time on various meaningless inspections of the hospitals, and useless meetings.

39. Doctors should not be focused on making money.

40. The difference in healthcare resource distribution is too uneven. The class-III hospitals control the majority of resources, while private hospitals have been suppressed for a long time. Private hospitals should be supported. Good mechanism should be built up so that fair competition, reasonable distribution of healthcare resources, and efficient patient allocation should be facilitated.

41. The low treatment cost is one of causes which lead to far too many patients in big hospitals; while there are few patients in small hospitals.

42. As long as the government does not pay the treatment costs for the poor, the relationship between doctors and patients cannot be improved.

43. Hospitals, particularly those mega class-IIIA hospitals, are monopoly organizations. There are many problems inside. Some of the big public hospitals should be detached from the government, so that they have to participate in fair competition in skills as well as in management. Human resource should have the freedom of movement. Doctors should be given time so that they can concentrate on treating patients.

44. The overall income of Chinese citizens is relatively low; the income of Chinese doctors should not be compared to doctors’ income in Western countries as well.

45. Much effort should be put into doctors’ skill training

46. Public hospitals should offer free treatment for some illnesses with seeking subsidies from the government. Patients will benefit; in the meantime, this will not be a big burden for the government.

47. Doctor is still a good profession.

48. To abolish the professional grading of medical doctors

49. The concentration of power by the department chairpersons is resented. A chairperson is in charge of everything in the department. Chinese bureaucratic formalities also increase doctors’ workload.

50. Clinical healthcare database should be established systemically at the national level. The information should be scientifically analyzed from time to time so to guide further policy making.

51. More comments are available at: http://blog.sciencenet.cn/blog-3000837-952956.html

References

1. Wáng YX. L YT. AME survey-003 A1-part1: in current China, do you regret you joined the medical profession. Quant Imaging Med Surg 2015;5:765-73. [PubMed]
2. Wáng YX, Káplár Z. L YT. AME survey-003 A1-part 2: the motivation factors of medical doctors in China. Quant Imaging Med Surg 2015;5:917-24. [PubMed]
3. Wu D, Wang Y, Lam KF, Hesketh T. Health system reforms, violence against doctors and job satisfaction in the medical profession: a cross-sectional survey in Zhejiang Province, Eastern China. BMJ Open 2014;4:e006431. [PubMed]
4. Bernstein J, Dunn EW, Horwitz DS. Not the last word: orthopaedic surgery is lucrative (but evidently not lucrative enough). Clin Orthop Relat Res 2015;473:418-21. [PubMed]
5. Kang S, Jo HS, Boo YJ, Lee JS, Kim CS. Occupational stress and related factors among surgical residents in Korea. Ann Surg Treat Res 2015;89:268-74. [PubMed]
6. Kim JH, Jung SS, Lee IK, Song BJ, Moon JH, Jang YS, Lee HJ, Lee ES, Lee WJ, Lee KY. Status and prospect of workforce requirement for surgery in republic of Korea. J Korean Surg Soc 2011;81:363-73. [PubMed]
7. Yoo MW, Lee IK, Ahn HS, Kim JW, Lee HJ, Lee KU, Yang HK. Survey of the residency training program in surgery. J Korean Surg Soc 2008;74:1-9.
8. Kang SH, Boo YJ, Lee JS, Han HJ, Jung CW, Kim CS. High occupational stress and low career satisfaction of Korean surgeons. J Korean Med Sci 2015;30:133-9. [PubMed]
9. Available online: http://www.mhlw.go.jp/shingi/2006/03/s0327-2d.html (In Japanese).
10. Health care in Japan: Not all smiles. Japan’s health-care system is the envy of the world. It is also in crisis. Available online: http://www.economist.com/node/21528660, The Economist. Sep 10th 2011.
11. Cheng AKH. Public doctors deserve reward for long hours. Available online: http://www.scmp.com/article/965573/public-doctors-deserve-reward-long-hours, Published: 20 April, 2011. South China Morning Post.
12. Azhar GS, Azhar AZ, Azhar AS. Overwork Among Residents in India: A Medical Resident's Perspective. J Family Med Prim Care 2012;1:141-3. [PubMed]
13. Friedlaender GE. The 80-hour duty week: rationale, early attitudes, and future questions. Clin Orthop Relat Res 2006.138-42. [PubMed]
14. Staiger DO, Auerbach DI, Buerhaus PI. Trends in the work hours of physicians in the United States. JAMA 2010;303:747-53. [PubMed]
15. Kristof K. $1 million mistake: becoming a doctor. Available online: . MoneyWatch September 10, 2013.http://www.cbsnews.com/news/1-million-mistake-becoming-a-doctor/
16. Wáng YX. On the training of young doctors in China. Quant Imaging Med Surg 2015;5:182-5. [PubMed]
17. Zhang Z, Wáng YX. English language usage pattern in China mainland doctors: AME survey-001 initial analysis results. Quant Imaging Med Surg 2015;5:174-81. [PubMed]
18. Wáng YX, Loffroy R, Arora R, Suzuki K, Lee CH, Chung HW, Oei EH, Winston GP, Ng CK. Relative income of clinical faculty members vs. science faculty members in university settings-a short survey of France, Hong Kong, India, Japan, South Korea, The Netherlands, Taiwan, UK, and USA. Quant Imaging Med Surg 2014;4:500-1. [PubMed]
19. Wáng YX. Income of medical doctors in Germany. Quant Imaging Med Surg 2015;5:488. [PubMed]
20. Heyes JD. Want to succeed in life? Don't become a doctor. Available online: http://www.naturalnews.com/044326_doctors_success_medical_career.html, Natural News, March 16, 2014.
21. Cooper RS, Kennelly JF, Orduñez-Garcia P. Health in Cuba. Int J Epidemiol 2006;35:817-24. [PubMed]
22. Campion EW, Morrissey S. A different model--medical care in Cuba. N Engl J Med 2013;368:297-9. [PubMed]
23. Shi J, Wang S, Zhou P, Shi L, Zhang Y, Bai F, Xue D, Zhang X. The frequency of patient-initiated violence and its psychological impact on physicians in china: a cross-sectional study. PLoS One 2015;10:e0128394. [PubMed]
24. Chappell D, Di Martino V. Violence at work (3rd ed). Geneva: International Labour Office, 2006.
25. Hahn S, Zeller A, Needham I, Kok G, Dassen T, Halfens RJ. Patient and visitor violence in general hospitals: A systematic review of the literature. Aggression and Violent Behavior 2008;13:431-41.
26. Magin PJ, Adams J, Sibbritt DW, Joy E, Ireland MC. Experiences of occupational violence in Australian urban general practice: a cross-sectional study of GPs. Med J Aust 2005;183:352-6. [PubMed]
27. Hahn S, Müller M, Needham I, Dassen T, Kok G, Halfens RJ. Measuring patient and visitor violence in general hospitals: feasibility of the SOVES-G-R, internal consistency and construct validity of the POAS-S and the POIS. J Clin Nurs 2011;20:2519-30. [PubMed]
28. Lepping P, Lanka SV, Turner J, Stanaway SE, Krishna M. Percentage prevalence of patient and visitor violence against staff in high-risk UK medical wards. Clin Med (Lond) 2013;13:543-6. [PubMed]
29. Belayachi J, Berrechid K, Amlaiky F, Zekraoui A, Abouqal R. Violence toward physicians in emergency departments of Morocco: prevalence, predictive factors, and psychological impact. J Occup Med Toxicol 2010;5:27. [PubMed]
30. Available online: http://health.chosun.com/news/dailynews_view.jsp?mn_idx=63057, Chosunmedia
31. Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US), 2000.
32. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf 2013;9:122-8. [PubMed]
33. Gill L, White L. A critical review of patient satisfaction. Leadersh Health Serv 2009;22:8-19.
34. Sitzia J, Wood N. Patient satisfaction: a review of issues and concepts. Soc Sci Med 1997;45:1829-43. [PubMed]
35. Pan J, Liu D, Ali S. Patient dissatisfaction in China: What matters. Soc Sci Med 2015;143:145-53. [PubMed]
36. Available online: http://www.dxy.cn/bbs/topic/32700436, accessed Jan 18 2016.
37. Wáng YX. Introduce fair competition mechanism in China healthcare system. Quant Imaging Med Surg 2014;4:498-9. [PubMed]