体制改变是8月18到21日深圳举行的世界癌症大会的主题，也是中国卫生部长陈竺在描述目前的中国医疗改革时传达的中心信息。在此次大会上主导关于讨论体制改变架构和行动的是许多中国之外的国际卫生政策制定专家和医生，而中国国内医生则很少参与其中。
要了解为什么众多负担临床一线工作的中国医生在体制改革会议中鲜有代表，你首先明白对大多中国医生来说个人安全才是他们的重点关注的。
中国医生常常深受恶性暴力袭击。
今年6月，山东省一位医生和护士被一名13年前肝癌死亡病人儿子刺成重伤，而在福建省一位儿科大夫为了躲避自己收治后病故的新生儿愤怒的家属从5楼跳下受伤。那么就不会奇怪为什么7月份沈阳市27家医院邀请派出所领导担任副院长了。一旦医院变成暴力战场，在中国做医生就变成了一份危险的工作。
问题很大程度源于一种看法，大许多中国病人相信医生和医院总是阴谋通过不必要的检查治疗来增加收费赚钱。此外一些中国医生违反规定收受红包（为了得到关照而付的礼金）。许多病人把卫生系统的***归咎于医生，谴责他们没有医德和技术。
中国古代知识分子的理想是“不为良相则为良医”，而在中国当代医生护士曾经被誉为“白衣天使”，怎么中国医生形象如此江河日下呢？中国媒体当然在挑动紧急的医患关系中起了重要作用。在报纸，电视和互联网上都是一边倒的关于医务人员如何欺骗患者的报道。就在几周之前南方都市报（广东最受欢迎的报纸）还错误谴责一位为产后出现痔疮的产妇治疗的助产士，说她蓄意将病人的肛门缝合。而在2009年11月中国最大的官方媒体，CCAV报导著名的北京大学第一医院允许医学生参与诊疗非法行医导致一名患者死亡。
尽管院方和卫生部申明相关的医学生在有资质的执业医生指导下参与临床操作包括手术是合法的，民众对医院和医生的信任却受到巨大伤害。很难判断南方都市报和CCAV的不实报道是因为缺乏医学知识还是为了要制造煽情的故事。但是公众对医疗职业的误解肯定最终会受到伤害的是医生和患者双方。
大多中国医院特别是像北京协和医院和复旦华山医院这样的大规模医院都是政府开设的。1985年之前中国的公立医院是享受完全政府拨款的，在改革开放之后现在政府对医院的经济支持非常有限，导致医院必须创收来应付支出。由于医院收入主要来源于诊疗措施，就存在过度检查和治疗的利益驱使。为了减少不当的利益冲突，中国政府通过法令来阻止医院收受药商回扣。因为中国医生的正式薪水即使按照中国收入标准也是不多的，许多医生在经济繁荣的中国不得不纠结于如何兼顾医德和养家糊口的两难。这样的压力加上感觉被政府和社会低估劳动价值，使得许多医生离职下海。
中国的卫生改革如果不改善医生的社会经济地位就不会成功，而中国医生应呼吁关注自身处境和建言献策来更多改进医疗政策。
System change, the theme of the World Cancer Congress in Shenzhen, China, Aug 18—21, was a central message in the opening address by the Chinese Minister of Health, Chen Zhu, as he described current health-care system reforms in China. At the Congress many international health policy makers and physicians led discussions on frameworks and actions for system change, but there was little participation from local Chinese doctors.
要了解为什么众多负担临床一线工作的中国医生在体制改革会议中鲜有代表，你首先明白对大多中国医生来说个人安全才是他们的重点关注的。
中国医生常常深受恶性暴力袭击。
今年6月，山东省一位医生和护士被一名13年前肝癌死亡病人儿子刺成重伤，而在福建省一位儿科大夫为了躲避自己收治后病故的新生儿愤怒的家属从5楼跳下受伤。那么就不会奇怪为什么7月份沈阳市27家医院邀请派出所领导担任副院长了。一旦医院变成暴力战场，在中国做医生就变成了一份危险的工作。
问题很大程度源于一种看法，大许多中国病人相信医生和医院总是阴谋通过不必要的检查治疗来增加收费赚钱。此外一些中国医生违反规定收受红包（为了得到关照而付的礼金）。许多病人把卫生系统的***归咎于医生，谴责他们没有医德和技术。
中国古代知识分子的理想是“不为良相则为良医”，而在中国当代医生护士曾经被誉为“白衣天使”，怎么中国医生形象如此江河日下呢？中国媒体当然在挑动紧急的医患关系中起了重要作用。在报纸，电视和互联网上都是一边倒的关于医务人员如何欺骗患者的报道。就在几周之前南方都市报（广东最受欢迎的报纸）还错误谴责一位为产后出现痔疮的产妇治疗的助产士，说她蓄意将病人的肛门缝合。而在2009年11月中国最大的官方媒体，CCAV报导著名的北京大学第一医院允许医学生参与诊疗非法行医导致一名患者死亡。
尽管院方和卫生部申明相关的医学生在有资质的执业医生指导下参与临床操作包括手术是合法的，民众对医院和医生的信任却受到巨大伤害。很难判断南方都市报和CCAV的不实报道是因为缺乏医学知识还是为了要制造煽情的故事。但是公众对医疗职业的误解肯定最终会受到伤害的是医生和患者双方。
大多中国医院特别是像北京协和医院和复旦华山医院这样的大规模医院都是政府开设的。1985年之前中国的公立医院是享受完全政府拨款的，在改革开放之后现在政府对医院的经济支持非常有限，导致医院必须创收来应付支出。由于医院收入主要来源于诊疗措施，就存在过度检查和治疗的利益驱使。为了减少不当的利益冲突，中国政府通过法令来阻止医院收受药商回扣。因为中国医生的正式薪水即使按照中国收入标准也是不多的，许多医生在经济繁荣的中国不得不纠结于如何兼顾医德和养家糊口的两难。这样的压力加上感觉被政府和社会低估劳动价值，使得许多医生离职下海。
中国的卫生改革如果不改善医生的社会经济地位就不会成功，而中国医生应呼吁关注自身处境和建言献策来更多改进医疗政策。
System change, the theme of the World Cancer Congress in Shenzhen, China, Aug 18—21, was a central message in the opening address by the Chinese Minister of Health, Chen Zhu, as he described current health-care system reforms in China. At the Congress many international health policy makers and physicians led discussions on frameworks and actions for system change, but there was little participation from local Chinese doctors.
To understand why there were so few Chinese delegates in the plenary sessions on system change compared with sessions on patients' care, one must first understand that for many Chinese doctors personal safety is of greater concern.
Chinese doctors are often victims of terrible violence.
In June this year, a doctor and a nurse were fatally stabbed in Shandong Province by the son of a patient who died of liver cancer 13 years ago, and a paediatrician in Fujian Province was injured after leaping out of a fifth-floor window to escape the angry relatives of a newborn baby who had died under his care. Thus, it is not surprising to see that in July police officers were invited to be the vice-presidents of 27 hospitals in Shenyang. With hospitals turned into battlegrounds, being a doctor has become a dangerous job in China.
The problem may be largely one of perception. Many Chinese patients believe that doctors and hospitals conspire to increase charges by providing unnecessary examinations, investigations, and treatments. Additionally, some doctors accept red envelopes (a monetary gift in exchange for favourable service) against the rules. Many patients blame the deterioration of their health directly on doctors, claiming that doctors lack devotion and skills.
The intellectual ideals of ancient China were “either to be a good prime minister or to be an excellent doctor”, while in modern China doctors and nurses used to be worshipped as “angels in white”. How has the perception of Chinese doctors become so eroded? The Chinese media certainly have an important role in provoking tension between doctors and patients. There is disproportionate coverage in newspapers, television, and on the internet of how health professionals have cheated patients. Just a few weeks ago the Southern Metropolis Daily (the most popular newspaper in Guangdong) falsely accused a midwife, who had treated haemorrhoids for a patient after childbirth, of stitching the patient's anus closed on purpose. In November, 2009, one of China's most authoritative media outlets, CCTV (China Central Television), reported that the renowned Peking University First Hospital was carrying out illegal medical practices by allowing medical students to do surgical procedures, and as a result a patient had died.
Even though the hospital and the Ministry of Health made it clear that involving medical students in clinical procedures including surgery under the supervision of licensed doctors is legal, trust in doctors and hospitals was seriously damaged.
It is hard to tell whether the misreport resulted from a lack of medical knowledge on the parts of the Southern Metropolis Daily and CCTV, or whether it was motivated by a desire for a sensational story. However, the public misunderstanding of the medical profession will surely hurt both doctors and patients in the end.
Most hospitals in China, especially the large ones such as Peking Union Medical College Hospital and Huashan Hospital of Fudan University, are run by the government. Public hospitals in China enjoyed full government funding before 1985. After economic reforms, the hospitals now receive very limited financial support from the government, with the result that hospitals must generate income to cover costs. As the main source of hospitals' income is from diagnostics and treatment, there is a financial incentive to over-investigate and over-treat. To minimise inappropriate conflicts of interest, the Chinese Government passed laws to prevent doctors receiving financial kickbacks from drug companies.
Because the standard salary of a doctor is modest, even by Chinese standards, many doctors struggle to balance professional ethics and making ends meet in an economically booming China. Such pressures, coupled with a sense of feeling seriously undervalued by the government and society as a whole, drive many doctors out of medicine into other jobs.
China's health-system reforms cannot be successful without reforming the social and economic status of doctors. Chinese doctors should be involved more in shaping health policy, by giving voice to their own experiences and constructive ideas about the health system.
The Lancet, Volume 376, Issue 9742, Page 657, 28 August 2010
