Wang Xiaoying / China Daily

Physicians less than receptive to medical reform, reports Yang Wanli in Beijing.

It's been two years since the Ministry of Health announced that physicians could practice medicine in more than one hospital or clinic.

The change, one of a series of medical reforms, would lead to a better distribution of healthcare resources and be well received, experts said.

Things have turned out differently. Far fewer physicians than expected have taken advantage of the change. Their reluctance may be due to the new policy's lack of clarity.

The ministry's announcement, in September 2009, placed restrictions on where they could work. While allowing doctors to work at more than one hospital or clinic, it encouraged them to remain within a certain province or municipality. And while it did allow them to practice medicine in more than one place it capped at three the hospitals or clinics where they could work.

The policy initially only applied to Guangdong, Hainan and Yunnan provinces and four municipalities. Not until July did the ministry apply it nationally. The response, in many places, has been less than enthusiastic.

Data from the Beijing Health Bureau show that only 166 physicians had obtained the right to work at more than one hospital by the end of June this year. That accounted for no more than 5 percent of the doctors who are known to in fact be working at two hospitals or more in Beijing, meaning that more than 90 percent of them still lack the legal right to carry on their practices in that way.

The results have been similar in other Chinese cities. People's Daily recently reported that only about 1,200 physicians had been registered in Kunming, Yunnan, by May 17, comprising only 5 percent of the city's physicians. In Guangdong, meanwhile, only about 100 physicians obtained legal registrations in the year following the policy change.

Often ignored

Zhang Mei's preferred place to go for medical treatment is the Sheng'ai Hospital of Traditional Chinese Medicine - one of the best-known private hospitals in Kunming. Zhang, a resident in Kunming, likes it so much that she has recommended to many of her friends and relatives, and they have started going there as a result.

Less than a decade after the hospital was founded, it employs more than 80 physicians who specialize in traditional medicine. All of them are retirees who had made their careers at well-known public hospitals.

"It's more convenient to see good doctors here, just with a little more money, and you get more time to talk with doctors about diseases," she said. "For many patients in public hospitals, good doctors are out of reach. There are fewer patients in private hospitals and, as a result, such places have better conditions."

Like many patients who are willing to pay to see the doctors they prefer and pay for what they consider to be better care, Zhang never thought about whether the retired practitioners at the Sheng'ai Hospital are working legally.

In the Chinese mainland, physicians can practice in clinics or hospitals after passing a national test and gaining a certification from a provincial bureau. That same certification will record the name of the place where they will work - usually a single public hospital.

Before the recent policy change, doctors were only supposed to see patients in the place written on their certification. But in reality, many doctors - especially those practicing traditional Chinese medicine or dentistry - were taking part-time jobs to earn extra money.

A physician at Sheng'ai who declined to provide his name said that most of his colleagues don't have the legal permission that would allow them to practice medicine at other hospitals.

"It is an open secret that almost all well-known traditional Chinese medicine doctors in public hospitals are taking part-time jobs in other places," the physician said.

Medical accidents have shown the dangers lurking in the system. In November 2010, a TV star named Wang Bei died while undergoing cosmetic surgery at a private hospital in Wuhan, Hubei province. The surgeon who operated on her was later found to be officially registered in Guangdong province, meaning he couldn't practice medicine legally in Wuhan.

Patients who seek treatment from "part-time" doctors are taking great risks, said the physician. They are less likely before surgery, for instance, to undergo preparations needed to make them as safe as possible and are also less likely to be observed by medical personnel following a procedure, he said.

Doctors' worries

To protect patients, the Ministry of Health is requiring doctors to obtain permission from both their employers and a health administrative department before they agree to work at more than one hospital. The physicians' licenses must bear the names of the new places where they will be working.

The ministry has also asked health administrative departments to release information about the demand for physicians in a timely manner, to guide the allocation of physicians to different hospitals and to encourage physicians to voluntarily practice in the countryside.

Although the door to obtaining a legal identity has been opened, many doctors are reluctant to walk through it.

A dentist from Beijing Stomatological Hospital, who declined to be named, said many doctors throughout the country have taken part-time jobs.

"Workers in private clinics earn much more than those in public hospitals," he said. "People tend to prefer to get dental treatment in those clinics, where they can get better service. And, of course, they pay more."

As an example, he cited the removal of wisdom teeth. He said that procedure usually costs no more than 100 yuan ($15) in public hospitals but can run as high as 800 yuan to 1,000 yuan in private ones.

Despite the advantages to working in private hospitals, he said most of his colleagues haven't applied for the legal right to have more than one place of employment.

"Our personnel relations in public hospitals bring us many benefits, which those private ones cannot, such as stable incomes and a good means of furthering our careers," he said.

He explained that physicians in the Chinese mainland are legally connected to the personnel system of a particular hospital, meaning they lack the freedom to choose where they will practice medicine.

Hu Guohua, vice-president of Shanghai Hospital of Traditional Chinese Medicine, said physicians are under the management of the hospital they are registered with. A hospital has the right to regulate those physicians' activities and can even revoke their medical certifications.

"Doctors will want to keep a good relationship with the hospital," he said.

"Besides, there are also things you can't get without relationships with people in a public hospital," he said. "For example, you can't get a position in a medical association or federation."

Hospitals' perspective

"Hospital leaders are concerned about the policy," said Hu. "If doctors take part-time jobs in other places, they will surely dilute some of their strength. I believe no president or patient of a public hospital would feel happy about this."

Moreover, Hu also worries about the loss of good physicians, which may further lead to decreases in the number of visits patients are making. "Apart from that, it is hard for us to supervise doctors when they are practicing outside," he said. "Their behavior will directly affect a hospital's reputation."

And what happens, he asked, if physicians who are registered at certain hospitals make mistakes at others?

"We may also have trouble because their certification is registered in our hospital," he said. "The (Ministry of Health's) notice didn't clarify the legal responsibility, and that is the main thing hindering this policy."

The notice does stipulate that physicians should work with the hospitals where they work part time to reach agreements clarifying who is legally liable in medical accidents or civil disputes that might arise from their medical practices. But it does not state specifically what the legal responsibilities are of the institutions that employ them.

"That is the problem we have been trying to solve recently," says Deng Kaishu, vice-president of Chinese Medical Doctors Association. He said that a group of experts in the association are planning to make a recommendation about the policy change and are asking for the notice's details to be made clearer.

He said hospitals often have insurance that will pay compensation to patients who suffer a medical accident in a hospital. But if physicians are practicing medicine part time at a second hospital, it is up to them to obtain their own insurance.

Deng said many insurance companies view such side practices as being inherently more risky and are reluctant to sell policies to physicians who have them.

He said physicians can earn more money in private hospitals. The basic salary in such places comes to 20,000 yuan a month. On top of that there are bonuses.

"Some private hospitals keep a small part of a physician's salary every month," he said. "By the end of the year, if no accidents have happened, the money will be given to the doctors.

"But this cannot be taken as a legal way of solving the problem," Deng said. "Practicing medicine in more than one place can lead to a better distribution of healthcare resources."

Private hospitals

Giving physicians the right to practice in other places seems to be a good beginning for both physicians and private hospitals. But to Zhao Tianwei, the chief physician at Mary's Hospital in Beijing, which specializes in gynecology and obstetrics, the policy change will have few obvious effects in the short run.

Zhao said there are about 10 physicians working at Mary's Hospital who have retired from well-known hospitals. She said none of them has obtained the official right to practice medicine at more than one workplace.

According to the Ministry of Health, both physicians who are retired and those in the midst of their careers must obtain the permission of all of their employers before they can practice medicine at two or more hospitals.

"When this is put into practice, it will give retired doctors more freedom to work in other places. But to be honest, we prefer to hire them instead of doctors who are still in the midst of their careers, even without the government's permission," she said, explaining that retired physicians can work full time and thus tend to make patients feel safer.

At the same time, she said the Ministry of Health's notice will lead to a better distribution of medical resources. And if more details of the policy are clarified in the future, private hospitals are very likely to hire more in-service physicians.

"Physicians in many advanced countries are independent," said Deng Xiaohong, deputy director of Beijing Health Bureau. "The relation between hospitals and doctors isn't simply about employment but also about cooperation. That helps patients enjoy good medical resources in the country. I believe that is the path that we are trying to take," said Deng.

She said that medical resources in China are concentrated in large hospitals. She also said that the Beijing bureau is encouraging more city doctors to practice medicine in rural hospitals.