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There are frequent conflicts and disputes between doctors and patients. How did the doctor-patient relationship evolve?

A few years ago, an article in China Medical Tribune introduced the evolution of the doctor-patient relationship, and the graph of the evolution of the doctor-patient relationship reflected the doctor-patient relationship from ancient times to the present.

Figure 1 Evolution curve of doctor-patient relationship

The medical level in ancient times was very poor, and diagnostic tools and treatment methods were scarce.Doctors mainly care and care for patients.. The doctor-patient relationship is an equal friend relationship, there is no commercial and economic relationship, and the reward is dispensable.

In ancient times, many people died of illness, and most patients and their families were grateful for the help of doctors. If the doctor doesn’t cure the disease in the end, the patient can accept it.

With the development of history, doctors have become a fixed practice, and the development of medicine has improved the diagnostic tools and treatment level. There is an unequal patronage relationship between doctors and patients, and doctors still can’t effectively treat diseases, mainly listening to patients’ needs and prescribing some symptomatic drugs, and patients often pay generous remuneration. At this time, doctors are subordinate and serve patients. Although their status is unequal, the relationship between doctors and patients is still relatively harmonious.

With the gradual improvement of doctors’ status, doctors’ authority is growing, and doctors are increasingly relying on laboratory tests and report forms. Doctors communicate less with patients, which invisibly widens the distance between doctors and patients.The status of doctors is gradually rising, and patients’ right to speak is relatively weak. In such a doctor-patient relationship, the patient is no longer the dominant position, and is completely dominated by the doctors in the hospital, so the contradiction between doctors and patients gradually arises.

An article in the New England Journal summarized the history of medical system reform in China when commenting on the root causes of doctor-patient conflict in China.

Since 1949, China’s medical system has been divided into four stages:

1. the first stage: imitating the national medical system of communist countries (1949~1984)

The government owns and operates all medical institutions, and all employees are government employees.There is no need for medical insurance at this stage, because all medical services are almost free.

At this stage, China’s medical system has made a remarkable achievement, such as the decline of infant mortality and the mass elimination of some infectious diseases.

2. The second stage: the new economic rules were implemented in the medical industry (1984~2003).

China’s medical system began to turn around. The financial support provided by the government to hospitals has dropped sharply, and many health workers have lost their financial subsidies.The government still owns the property rights of hospitals, but it has little intervention in the behavior of medical institutions.In a market system lacking rules, these nominally public hospitals began to act like profit-seeking enterprises. Doctors employed in public hospitals can get a considerable bonus if they make a profit for the hospital.

At this stage, the government only provides medical insurance to some people, and private insurance companies do not exist at all; As a result, most people in China are not covered by medical insurance, which makes the turbulence caused by the experiment of market-oriented medical reform more intense.

By the late 1990s, this market-oriented reform experiment had led to public anger, distrust of hospitals and medical practitioners, and even developed into a widespread violent attack on doctors.In some underdeveloped rural areas, the dissatisfaction caused by looking down on illness has triggered public protests, which has threatened social stability.

3. The third stage: 2003 version of medical reform (2003-2008)

Adopt a medical insurance system (new rural cooperative medical insurance)Slightly subsidize the hospitalization expenses of the rural population to alleviate social protests.. This medical insurance requires hospitalization to be reimbursed, which reflects the fact that hospitalization expenses were expensive at that time and many rural families were poor due to illness.

Policymakers’ minds are all occupied by how to reduce the expensive hospitalization expenses, and they don’t realize that "in order to manage health, treat diseases and control expenses, strengthening primary health care is the key link".

4. The fourth stage: 2008-present

Policymakers have realized that the medical insurance system and hospitals need to undergo major reforms, otherwise social stability will be endangered.This time, the medical reform announced to abandon the experiment of medical reform mainly based on market principles, and promised that by 2020, affordable basic medical services could be provided to all the people.

At the end of the article, some main problems are pointed out. First of all, tertiary hospitals have successfully resisted the latest medical reform. Secondly, there are still a lot of inequalities between poor rural areas and rich areas. Third,To form a high-quality, reliable and professional group of doctors in China, we have to make a hard struggle.. In the past, a great legacy of China’s market-oriented medical reform was that the public generally believed that doctors put their own economic welfare above the interests of patients, and it was not easy to completely reverse this concept.

Can money completely alleviate the conflict between doctors and patients?

Finally, a dopamine said in its article, "If it is free to see a doctor, or only a very small amount of money is needed, I think the relationship between doctors and patients will be eased immediately." Is that really the case?

There are still some people who basically don’t need money to see a doctor. Are they satisfied with medical treatment? The answer is of course no.

Their experience in the environment and process of medical treatment is often very poor. Even if you don’t have to bear the medical expenses yourself, and doctors will not be restricted in medication and examination, you still can’t satisfy patients. If the final outcome of treatment is bad, conflicts will still occur.

Professor Hu Dayi pointed out in an interview that,The root of doctor-patient conflict is the marketization of medical and health care.. He said that after putting the whole medical service on the market, it is impossible for doctors to help patients make behavioral changes except over-treatment. After turning medical service into a complete business model, the contradiction between doctors and patients will certainly become more and more fierce. In the past 30 years, the development of hospitals has been pushed to the market, which has led to the monopoly of medical resources by many giant hospitals. Hospitals rely on making money from patients to increase operating income, buy equipment, build houses and give bonuses.Big hospitals have kidnapped other hospitals, and all hospitals have to run wild on this system. All doctors are victims or victims.

Academician Han Qide pointed out in an interview that the contradiction between doctors and patients is the progress of medicine and society.The improvement of medical effect leads to a great increase in patients’ expectation. When the untreated patients become a minority, it is more likely to produce psychological imbalance.. At the same time, with the development of medical technology, doctors have shifted almost all their energy and attention to technology, and getting along with patients has been put in a secondary position, and the distance between doctors and patients has become larger and larger. The direct consequence of the improvement of modern medical technology is that the cost and price of medical care have greatly increased. The increase of expenses will double the pressure on patients and decrease their satisfaction, which will aggravate the contradiction. He also stressed that doctors are facing life, and in any era, doctors’ moral requirements cannot be lowered, otherwise, combined with information asymmetry, medicine will become very terrible.

Where is the outlet of doctor-patient conflict?

Lao Liu’s mother, as a retired doctor who has undergone free medical care and the first medical reform, recently read some articles on medical reform policies shared by old comrades, and repeatedly pointed out that medical care should be restored to the previous free medical care system for all.She said, no matter which countries are poorer or richer than ours, they can realize free medical care. Why can’t we?

After listening to this, Lao Liu smiled indifferently, not to mention paying medical expenses for all patients, that is, ensuring the normal operation of public medical institutions at all levels, paying reasonable wages and allowances in full by staff, regularly updating and maintaining instruments and equipment, opening medical service institutions in areas lacking medical services and medicines, and ensuring the implementation of other social work such as public health, anti-epidemic work, health care and rehabilitation.The cost that the government needs to bear may be astronomical.If medical insurance is not charged and social security funds are not paid, the medical expenses will be even more alarming. With such a large population in China, how can the state realize huge investment in the health system through taxation? Although I don’t know much about the economy, it’s hard to achieve it by rough thinking.

When I was young, I remember that there might be only one or two antibiotics at that time, which was very cheap. Image examination is film machine and ultrasound examination, and blood examination is also very limited. The quantity of drugs is limited, and many diseases are not treated with drugs. At that time, it was simple and cheap to see a doctor once. Surgery is a direct operation, no endoscope, no robot, and lack of instruments and instruments, and the cost is relatively low.Perhaps free medical care was possible at that time, so it is too difficult to realize the development of medicine today.

Some countries can provide free medical care, or provide the most basic medical security, or build on the basis of high taxes, or the country has less people and more money. Looking back at China’s population of more than one billion and the level of medical development, it seems a bit difficult to go back to the past.

As pointed out in the book Chinese doctor-patient relationship,The conflict between doctors and patients is not only a moral problem, but also an institutional problem. Morality needs long-term construction, and the system can be effective in the short term.To solve the conflict between doctors and patients, the fundamental way out is to eradicate the drawbacks of the medical system and use "restructuring" to incite "change of heart". The book also points out that in a reasonable medical system, the interests of doctors and patients are the same. The lower the cost of patients’ treatment, the less the social medical expenditure, and the more rewards doctors get. In order to eliminate the crisis of trust between doctors and patients from the root, we must reform the medical system of supporting doctors with medicine and supporting doctors with machinery, so that doctors can eat by technology instead of selling medicine.

In recent years, medical reform measures have continued, from the procurement of drugs with quantity and the procurement of high-value consumables in sunshine, and the medical insurance policy has been constantly changing. Is the patient feeling well? Has the practice environment of doctors improved? Has the contradiction between doctors and patients eased? It’s still time to give an answer.

How do you feel after the medical reform?

References: China Medical Tribune Today’s Stomatology, No.171, 03~04 edition.