- PS-CMDA —
- Pediatric Society of the Chinese Medical Doctor Association
Chinese pediatricians face a crisis. Not only is there a shortage of pediatricians, but their numbers are actually decreasing.1 In 2012, there was only 0.43 pediatric specialist for every 1000 children, or ∼96 000 pediatricians for the 220 million Chinese children aged <14 years. By comparison, in the United States, the ratio is ∼1.46 pediatricians for every 1000 children.2 Based on this ratio, China is short at least 200 000 pediatricians. A recent event called attention to this shortage. At a 2013 recruitment event for medical staff for the Women and Children’s Medical Center and Children’s Hospital of Dalian, no one was willing to apply for any of the 22 open pediatric positions. Of the 27 physicians who had been offered a position within the public institution system via open recruitment, 9 declined their offers. Among the 18 physicians who did report to work, 3 resigned after <1 month because of the high job pressure and low salary.3 Similar dilemmas are present in pediatric hospitals in Anhui, Zhejiang, Shanghai, and other provinces in China. Individuals recruited through open recruitment by public institutions in China have a regular salary and a career-long job there until retirement, regardless of their performance, but even with these advantages, pediatricians still choose to leave.
Because of the shortage of pediatricians, many Chinese hospitals have been forced to dissolve their pediatric departments. According to the Pediatric Society of the Chinese Medical Doctor Association (PS-CMDA), although children account for 20% of the total population in China, there are only 68 specialized hospitals for children with a total of ∼258 000 beds, representing only 6.4% of all hospital beds.1,2 Compared with the huge demand for hospital care, pediatric medical resources are limited. In particular, almost all of the large pediatric hospitals are in big cities. As a result, large volumes of pediatric patients swarm to the limited medical resources, leading to long wait times and difficulty in seeing a pediatrician.
According to data provided by the PS-CMDA, during the busiest time in Beijing Children’s Hospital, there can be, on average, 4000 visits to the pediatric outpatient clinics in a single day. Because the department has between ∼40 to 50 pediatricians, each physician is typically responsible for 80 to 100 visits each day, and sometimes up to 150 visits per day. Based on this scenario, the average patient encounter is 6 minutes. Pediatricians hardly have time to eat or use the bathroom.4 Similar conditions have also been seen in other pediatric medical centers, where high job intensity is considered normal. The shortage of pediatricians in China is alarming, and it is becoming common to stand in a long line for several hours in pediatric clinics. Access to high-quality medical services can be difficult, and many patients experience delays in diagnosis and treatment.
Unfortunately, many families do not understand the predicament that pediatricians face. Because of the 1-child policy in China, parents and grandparents pay great attention to the health of their child. Many families will instinctively blame physicians if conditions worsen, regardless of the cause. The frequency of medical disputes in pediatrics is higher than for other specialties. In fact, pediatricians receive insults and have been threatened with assault and murder.5 In 2002, violence against a pediatrician occurred in the First Hospital of Nanhua University. Xiaoping Yuan, MD, was paraded around the hospital and insulted for 4 hours by hundreds of family members because their infant had died of severe respiratory failure and acute respiratory distress syndrome. The family hired “hospital violators,” a professional group used during a medical dispute to help gain higher compensation from the hospitals by disrupting their normal medical practices. The family blamed Dr Yuan and attacked him viciously, leading to severe physical and psychological harm. This violence shocked the entire nation.6 Worst of all, the event set a bad precedent for all patients involved in medical disputes with physicians. Afterward, an increasing number of clients decided to resort to violence in place of using legal means. The PS-CMDA reported 831 incidents of serious medical violence in pediatrics in 2006. At least 319 medical workers were attacked, and several pediatricians were beaten to death or disabled.7 Similar data were also reported by the Dingxiangyuan online network, a national medical Web site; the number of incidences of medical violence in which pediatric workers were injured or murdered in China was 5 in 2006, 7 in 2008, 10 in 2010, and 15 in 2013. The incidence of medical violence is increasing by nearly 20% annually. Careers in pediatrics have become very dangerous in China.7
Even if these issues could be resolved by pediatricians and the Chinese medical system, the low salary these pediatricians receive is a major cause of frustration. A survey of physicians’ salaries, performed by PS-CMDA, found that, in 2011, ∼96% of pediatricians were not satisfied with their salaries and believed there was an imbalance between their income and job intensity.7 In China, public hospitals receive very limited financial support from the government, requiring hospitals to generate income to cover costs. Most of the medical service costs are from medications, disposable materials, and expensive diagnostic tests rather than from the actual diagnosis and treatment provided by physicians. For example, the fee to see a pediatrician is only $1.12 for a professor compared with $43.07 for a general ultrasound examination.
Generally speaking, the shortage of pediatricians would increase their value, but that is not the case. The value of medical services provided by physicians is low; therefore, it is impossible for the shortage of pediatricians to result in a meaningful increase in their value. As with other physicians, pediatricians have to compensate their salaries by selling medicines and prescribing expensive equipment inspection to increase the hospital’s income, from which their salary is derived. However, the amount of medications used and the number of expensive equipment inspections are relatively small; thus, pediatricians do not have the same opportunities to supplement their salaries as do other physicians. Because this “gray income” from unusual sources such as patient bribes and financial kickbacks from drugs, disposable materials, and medical devices is often their main income source, most pediatricians have lower incomes than other physicians, even though their legal incomes may be equal.
Nanshan Zhong, the deputy to the National People’s Congress and academician of the China National Engineering Research Institute, performed a survey of the salaries of physicians from hospitals in Guangzhou. The results demonstrated that, in 2012, the average income provided by hospitals (book income) to general physicians was $6576 and their average total income, including book income and gray income, was $28 229. In 2013, the average book income was $7371 and the total income was $31 430.83. In contrast, the book and total income of pediatricians in 2012 were $5130 and $18 927 and in 2013, it was $5792 and $20 547, respectively.8 The earning power of pediatricians is far from that of other physicians, and it is not commensurate with the high intensity and high risk of the job. The imbalance between the lower salary level and high job pressure is likely the most direct cause of the exodus of pediatricians from this profession.
Based on these and other factors, an increasing number of pediatricians are choosing to leave the profession. According to data from the PS-CMDA, at least 2 pediatricians per hospital leave their positions annually. Furthermore, at least 300 pediatric positions to be filled through open recruitment had to be canceled because the minimum number of candidates was not reached. Chinese pediatricians who have been fleeing the profession tend to enter either the administrative department or the laboratory of their hospital. Other options include pursuing a different medical field, working for a medical company, going abroad, or even leaving medicine entirely. In addition to the decrease in trained pediatricians, medical students are choosing not to become pediatricians. Most of them would rather leave medicine than become a pediatrician.
Despite this crisis, little is being done by the Chinese government to stop the loss of pediatricians, by either increasing their pay, decreasing their job intensity, or attempting to prosecute the violence committed against pediatricians. The government needs to play a leading role in dealing with this crisis by writing and implementing appropriate laws and establishing fair and objective third-party accreditation bodies. Increasing the investment in pediatrics from public finances, easing the pressure on pediatricians, eliminating the practice of physicians supplementing their income by selling medicines, and increasing pediatricians’ salary levels are possible steps that will lead to more pediatricians willing to stay in the profession.4,7
With no help coming from the government and no public support, pediatricians are faced with the dilemma of whether to transfer to less dangerous, better-compensated careers. We, the authors of this article, are pediatricians and do not know how long we will remain so. Perhaps one day we will choose to leave also.
- Accepted August 11, 2014.
- Address correspondence to Shu-Cheng Zhang, MD, Department of Pediatrics, Shengjing Hospital of China Medical University, 36 SanHao St, Heping District, Shenyang, Liaoning, 110004, PR China. E-mail:
Drs Zhang and Xu contributed equally to the manuscript. They conceptualized and designed the study, coordinated and supervised data collection, drafted the initial manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- 2.↵Ministry of Public Health. China Health Statistical Yearbook 2013. Beijing, China: People’s Medical Publishing House; 2013:111–114
- 3.↵China Medical Tribune. (2013) Dalian pediatrician open recruitment: no candidates? In Chinese. Available at: http://ped.cmt.com.cn/detail/405753.html
- 4.↵Chinese Medical Doctor Association. (2013) Paediatricians flee away in China. In Chinese. Available at: www.cmda.gov.cn/xinwen/redianxinwen/2014-01-24/12845.html
- 6.↵People’s Daily Online. (2002) A pediatrician was paraded and insulted for 4 hours by dozens of hospital violators in the beginning of medical dispute. In Chinese. Available at: www.people.com.cn/GB/shehui/45/20020520/732031.html
- 7.↵News.163.com. (2013) Chinese doctors are under threat. In Chinese. Available at: http://news.163.com/special/reviews/zhongguoyisheng.html
- 8.↵The South City News.(2014) Nanshan Zhong: the average income of doctors from the third-grade class-A hospitals in Guangzhou is 46042 Yuan in book and 196320 Yuan in total in 2013. In Chinese. Available at: http://news.china.com/2014lh/news/11151572/20140305/18376747.html
- Copyright © 2014 by the American Academy of Pediatrics