At a time when the pressure for income, scientific research and promotion is increasing, and the contradiction between doctors and patients continues to worsen, one doctor bluntly said that if the torture caused by lack of material or lack of safety exceeds the spiritual enjoyment brought by clinical practice, he "will choose to leave."

————"Nandu Weekly"

1 The series of murders and murders made Lin Can (pseudonym) angry at first, and then shaken. He said: This has a huge impact on medical students.

Lin Can is a first-year graduate student majoring in ophthalmology at a medical school in Shanghai. Earlier, he was fascinated by watching the medical drama "Infinite Vitality": There is a team of detached doctors in the drama. When patients come and say they have no money, they treat them and use good medicines at the right cost; when the condition is critical, they can use their insight to do the best. The medicine will cure the disease.

"Now it seems that this is a beautiful yearning, rather than a reflection of reality." Lin Can said that what supports medical students is a "trapped" mentality similar to that in the stock market – they are reluctant to cut their flesh, so they maintain the status quo.

He remembers that when he was an undergraduate, his seniors taught him that since he was in a key medical school and could not just go to a local hospital to be a general practitioner, then taking the postgraduate entrance examination would become his goal. Now, he can predict that when he finishes graduate school, his instructor will inevitably say: It has been three years, I have learned a lot, and I am one step away from victory. It would be a pity to stop.

Even if you live up to your mentor's expectations and enter the hospital directly, a doctoral degree will still be a hard indicator when it comes to being promoted from a resident doctor to an attending physician.

With 5 years of bachelor's degree, 3 years of master's degree, and 3 years of doctoral degree, followed by 1 to 3 years of residency rotations, medical students' prime years are squeezed into protracted studies and clinical internships.

Once on the highway, Lin Can couldn't idle or turn around and go the wrong way. His undergraduate classmates who were not admitted to graduate school were all making compromises. For example, one who once determined to be an orthopedic surgeon went to the auxiliary department.

"As a 26-year-old boy, I am still a student. I have no income, cannot support myself independently, and have no time to spend with my family." Lin Can said frustratedly, "I feel ashamed of my family by choosing to study medicine, and the society does not understand us."

2.

What Lin Can said he didn't understand was a medical dispute. Once when I went to see a doctor with my tutor, he was doing paperwork. There was a patient who had been waiting in line for a long time to undergo eye surgery. After examination, the instructor found that there were other problems and it was not suitable for surgery at the moment. He suggested that he go to another department to eliminate the hidden dangers first. The family members thought they had been "kicked", so they came to criticize: Aren't you a very good professor? Are you not number one in the world? Why can't you treat such a disease?

The instructor argued with him excitedly, and the situation got out of control.

"This attack on you is sudden." Lin Can said, "The doctor will be stunned and think it is not my fault."

According to statistics from the Ministry of Health, in 2010 alone, a total of 17,243 medical incidents occurred across the country, nearly 7,000 more than five years ago.

Since 2012, there have been more and more cases of doctors being harmed. In addition to the previous stabbing incidents in Harbin Medical University and Beijing and other places, in the early morning of May 5, at the First People's Hospital of Jingzhou, Hubei, a patient who was lying on the operating table in the emergency room preparing for surgery suddenly sat up. Jumped off the operating table and started chasing the doctor. The doctor involved said that he was asking and checking the injured person's information as usual.

Sometimes, if he changes his position, Lin Can also understands the patient. "The patient has become irritable after waiting for treatment for a long time. Once a problem occurs or a certain situation requires further treatment, his mentality will be completely bad." Lin Can said.

But queuing is unavoidable. In the tertiary specialized hospital where Lin Can is located, an ophthalmologist sees about 100 patients a day, from 8 a.m. to 1:30 p.m.

Lin Can admitted that "the level of detail in medical examinations is very limited". "We can only see if there are any problems in the eyes, measure the intraocular pressure, and check the degree. If it is myopia, we will ask you to get glasses."

"For outpatient doctors, firstly, they must make no mistakes, and secondly, they must try to identify hidden dangers." Lin Can understood this. "Routine examinations have become a pattern. Once the examination is done, general symptoms can basically be reflected."

"Many patients complain: Are you giving me a checkup without asking anything?" Lin Can answered honestly: "I really don't have time to ask."

3.

Xu Xia (pseudonym) works as an anesthesiologist in a triple-B hospital in Jiangsu and has 17 years of medical experience. She works six days a week. She arrives at work at 7:45 on working days and is busy for 7 hours. She is supposed to get off work at 14:45, but she has to work overtime almost every day.

There are 30 doctors in the anesthesiology department. Under normal circumstances, some of them are on emergency duty or taking shifts. About 12 people can work on the surgical shift, and they have to handle more than 70 surgeries a day.

Xu Xia often works overtime until 5 or 6 pm, or even 11 pm at night. The corresponding overtime pay is 5 yuan an hour, which is a bit lower than McDonald's hourly workers.

"It takes up too much time. We are no different from workers on the Foxconn assembly line." Xu Xia complained, "And overtime is institutional. Even if you don't get a penny, you still have to work unless you resign."

Another problem is that this amount of effort has not produced much benefit, and the technical value of doctors has not been reflected in the fees.

Xu Xia gave an example: For the most famous professor at Peking Union Medical College Hospital, the registration fee for the expert clinic is 14 yuan; for a seven or eight-hour intubation general anesthesia operation, the anesthesia fee is about 490 yuan, and the general anesthesia without intubation charges 190 yuan. ; A major surgery requires the collaboration of 5 to 6 surgeons, 2 anesthetists and 2 nurses, takes several hours, and costs from 1,000 to 3,000 yuan.

"Doctors' technical efforts are at a loss, and hospital income is made up of drug commissions and examination fees." Xu Xia said frankly, "Some hospitals have drug rebates, some do not, and the distribution methods are also different. In most cases, Ordinary doctors get very little.”

“Now, in the eyes of the public, doctors have become a group of profit-seeking clowns.” Dr. Xie Rushi from the Sixth Affiliated Hospital of Sun Yat-sen University said, “But doctors are also human beings. They not only have to live, but also are responsible for the construction and development of the hospital. .”

He revealed that under the current system, in most hospitals, the annual government allocation is less than 10% of the hospital's total expenditure, and even less in university-affiliated hospitals, less than 6%.

"You said that if the hospital doesn't make money, will patients have such an environment and equipment when they go to the hospital for treatment? Will there be so many experts?" Xie Rushi asked.

In 2010, Xu Xia was working hard and had an annual after-tax income of less than 60,000 yuan, which included salary, bonuses, holiday pay, overtime pay and surgical allowances.

Xu Xia also received red envelopes. She struggled against temptation and indeed needed money. She herself said that she stopped taking it later because "the purification of society requires everyone's efforts." Another reason: receiving red envelopes is risky. She said: "It's too easy to find mistakes in medical treatment. Doctors don't accept red envelopes and are even hacked and killed."

"Accepting benefits is not a problem for individual doctors, but there is no good system to restrain this behavior, and there is no good system to help doctors realize their value," she added.

4.

Xu Xia introduced that bonuses for hospital departments are calculated by the hospital department. The principle is income minus losses. "But the specific amount still depends on the weight of the department director."

She remembered that in January and February this year, one colleague only received a monthly bonus of NT$800, and doctors in departments with good results only received a bonus of NT$5,000.

Xu Xia said: "The amount of the bonus is related to the status of the department. The stronger the department, the more say the department director has in front of the dean, and the bonus will be higher."

This bonus will be distributed uniformly to each department, and the department will arrange for people to calculate and distribute it according to a coefficient, which is linked to each doctor's working years and professional title. The coefficient for new doctors in the first year of work is 0, with no bonus; in the second year, it is 0.5; in the third year, it is 0.75.

Commensurate with the meager income is the working environment. The hospital where Xu Xia works has a fluidized bed system in the operating room, which is used to regulate temperature, exchange gas with the outside world, and sterilize. However, the hospital stipulates that the flow layer must be turned off after the operation.

"The cost of use is only the electricity bill, and the hospital must save electricity bills." Xu Xia did not understand that some minimally invasive surgeries, such as laparoscopic gallbladder surgery, require filling the patient's belly with carbon dioxide to make the belly bulge, and there is a lot of waste gas during the whole process. Trapped in the operating room. Turning off the flow layer immediately after the operation will result in a poor indoor environment.

"Over time, many colleagues have headaches." Xu Xia said that they put forward opinions to the leaders. The leader said "Oh" and said: No wonder I have a headache recently. But there is no more.

Another system also causes headaches for doctors. The hospital stipulates that if a patient evades the fee, the doctor concerned will pay the owed fee. In Xu Xia's hospital, there was a team of doctors – three orthopedic surgeons – who jointly treated an inpatient. At the end of the treatment, the patient escaped and owed 19,000 yuan in medical expenses. The hospital determined that it would fine the team leader, the deputy chief doctor, 10,000 yuan, and the other attending doctor would bear a fine of 9,000 yuan.

"So if you go to the hospital and you have no money, the doctor will stop your medicine." Xu Xia revealed the reason, "Clinicians have become very good at it. If they don't pay, they will stop the medicine. They even have to pay the surgery fee in advance."

5.

If drug withdrawal occurs, some people will use "medical ethics" as an excuse. Like many doctors, Zhu Huan (pseudonym) doesn't like the word "medical ethics." He is a resident doctor in a tertiary hospital in Beijing. He feels: I treat patients well not because of medical ethics, but because I have sympathy for the patient's pain, and I also gain moral satisfaction in the process of showing sympathy.

Zhu Huan believes that whether a person is suitable to be a doctor is innate. If he can only take exams, it is not enough. He said: "Clinicians focus on bedside consultation and judgment of illness. If you don't like dealing with people, don't have basic sympathy, observation and judgment, you are not suitable to be a doctor."

"The next question is, is it suitable to be a doctor in China?" Zhu Huan continued, "If you can't stand the high investment and low returns, you can choose to leave."

For Zhu Huan, what he pursues is the joy of rigorous reasoning and catching the "real murderer" during clinical diagnosis and treatment, and the sense of accomplishment of accepting the trust and respect of others with peace of mind.

Sometimes the fun and sense of accomplishment are ruined. Zhu Huan said that if you have a tumor, you need to treat it. With treatment, there is only a 40% chance of remission. Without treatment, there is no chance.

"Most people are not willing to admit defeat, and are only willing to absorb information that is beneficial to them." He said, "A medicine may be useful, but the condition will develop and change. The medicine may be useful to others, but it may not be useful to them. What works now may not always work in the future.”

Xu Xia agrees with this. She feels that patients have too high expectations of doctors because of a lack of popular science. Modern medicine has its limitations and many diseases are still incurable.

Zhu Huan feels that Chinese people’s thinking and cultural traditions are not suitable for Western medicine. It is widely spread that they believe in miracles and individual cases, but do not agree with probability theory.

He still took cancer as an example. Medicine has a prediction for cancer, with a 50% chance of living for three years and a 20% chance of living for five years. The doctor tells the patient step by step that every treatment choice may be right or wrong. "To put it exaggeratedly, 90% are right, 10% are wrong, the 10% that are wrong can still be used for the next move, and the last 1% may be death. Some people wonder why this 1% is irreversible, right? No red envelope?"

He said: "Medical care is not a service industry. We and patients are comrades-in-arms. I sympathize with you and that's why I help you. You have financial resources, are willing to lose your hair, can endure pain, and have expectations that you may lose both your life and money. Doctors and Only when patients reach these consensuses can they move forward.”

6.

Zhu Huan didn't want the doctor and patient to be so careful that every step of treatment required the doctor's signature and then the patient's signature.

"Now take your life and slap it on the table. I will help you bet. Do you want to bet?" He said, "Patients should stand with doctors to fight against the disease. If the preset position is to buy services, Sorry, there are some services I don’t sell.”

Zhu Huan had seen patients kowtow and kneel. He insisted that this was the story of the farmer and the snake. "A patient who can kneel down will come back to sue you later because he values ​​his dignity lower than his life."

For such patients, Zhu Huan would avoid dangerous operations as a way of self-protection.

Zhu Huan said that his hospital is somewhat of a spiritual home, but this does not represent the entire medical environment. In his department, there are no kickbacks or red envelopes, and the medication and treatment are all in accordance with the standards. Most doctors will not discuss houses and stocks. Everyone has sentiments and thoughts.

As for excessive examinations, he explained that some doctors are afraid of taking responsibility and prescribe more examinations. "If you prescribe too many tests, at most you will say that he is not good enough and is not good at studying medicine. But if you let a cancer patient go, he will be misdiagnosed."

Zhu Huan said that he did not rule out that there were indeed bad doctors profiting from it. For example, if a private hospital buys equipment, they go to the outpatient clinic of a large hospital and hand the doctor a business card, give him a kickback, and say: I have idle equipment here.

"At best, this is a redistribution of medical resources." But Zhu Heng believes that as long as the information asymmetry and financial temptation between doctors and patients still exist, these dark spots are inevitable. He also pointed out that in some countries, if a doctor prescribes more examinations, the market mechanism can restrain him, and the insurance company will require him to pay more insurance premiums.

7.

Most people were high school students when they chose to study medicine and had not developed any values. Their parents said they could make a lot of money in this profession, but they later found out that this was false.

"If one day, the torture caused by lack of material or lack of safety exceeds the spiritual enjoyment brought by clinical practice, I will leave." Zhu Huan said.

Huang Wen (pseudonym) finally chose to relax himself after practicing medicine for two years. Previously, he worked as a resident doctor in a tertiary hospital in a provincial capital city.

Huang Wen remembers that it was quite relaxing during his master’s internship. During the rotation period, he had to work the night shift alone in a ward, with only one nurse and one doctor caring for him all night. When he encounters a problem that he doesn't know how to deal with, or cannot handle independently, he can call the general on-duty staff. If the problem cannot be solved after telephone consultation, the general on-duty staff will come over. Typically, the general on-call staff is a junior attending physician.

In the second month of the rotation period, Huang Wen independently handled a death during the day. He said that all doctors have the courage and are not afraid of facing the deceased, but are afraid of trouble from the family members. "When a patient dies, we will feel morally sad. Young doctors who have just started working all feel this way. If a patient who has been taking care of for more than 10 days dies, we will feel lost."

Once, Huang Wen participated in a cardiac interventional surgery and complications occurred, but the patient did not die. "Each patient has a different constitution and anatomical structure. I just started working and have seen few cases. When I use my past experience to deal with it, problems arise."

"Fortunately, the rescue was successful and there were no sequelae." Huang Wen said that the complications were explained in the pre-operative informed consent form, and the family members also signed it. But once there are sequelae, even if the family members signed it, they will come to ask for explanation. .

This incident hit Huang Wen hard. He said that after complications occur during surgery, most doctors will "close the operation" – take a short break, and some doctors will go to temples to burn incense.

8.

Huang Wenwen has been practicing medicine for 7 years and entered a tertiary hospital. His future seemed bright, but at that time, he felt deeply stressed. He said that every promising doctor has the sword of "SCI paper" hanging over his head.

Large hospitals generally have rules: when a doctor is promoted to attending physician, or when he applies for a project and obtains funding, he must first publish a paper in a journal indexed by SCI.

"You have to do animal experiments, write articles in English, and spend all your spare time in it." Huang Wen said, he understands that following this path and surgeons becoming chief surgeons may bring gray income; internists After becoming famous, you will have academic status and social reputation.

"These require extremely hard work and a long time." Huang Wen said that he hopes to live happily in a short period of time. The stage of being a junior doctor is very difficult.

Moreover, in Huang Wen's department, some patients died due to complications after surgery or unpredictable situations.

He said there was an unspoken rule: "Most of the medical records that the hospital thought might cause disputes had been modified."

"The director of the department judged that a certain medical record would be implicated in a lawsuit, so he ordered the junior doctor to rewrite it, requiring the wording to be appropriate and rigorous, and to plug all the loopholes. Some operations were performed by the doctor but were not included in the medical record. Make up for it. After writing it, several doctors take turns to read it, and then copy it down once there is no problem."

Huang Wen heard an old doctor say that in the past, when the doctor-patient relationship was less tense, an appendix surgery might only have one line written on the medical record: laparotomy, exploration, appendectomy, and skin suturing. Doctors now have to write: Carefully separate the appendix layer by layer, no bleeding is seen, follow the steps to remove the appendix, and explore step by step.

"I saw that there was pus here and there was no pus there, but the appendix was infected. How to cut it was written in detail, so I was afraid of a lawsuit in the future." Huang Wen said.

The pressures just converged. In his first year of work, a pharmaceutical company contacted him, "I would definitely be excited about the opportunity to double my income." But Huang's parents disagreed.

"Step by step, if there is temptation outside, you will think about it." During the Spring Festival of a certain year, Huang Wen spent time in the emergency room of the hospital. At that time, he thought about leaving again.

In the second half of this year, Huang Wen resigned and went to a medical company, citing personal reasons.

At the end of the interview, he sat in the coffee shop in the podium of the office building and told reporters in a soothing voice: "In the company, there is no need to work night shifts, no need to write SCI papers, and no doctor-patient disputes. I will feel that my social status is It’s lowered, but the mentality can be adjusted.”

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