Chinese doctors are under a high risk of sudden death
Editorial

Chinese doctors are under a high risk of sudden death

Zhantao Deng1*, Jiewen Jin2, Qiying Dai3, Jingxin Pan1*, Xiaoyan Wang4*, Rui Liu5*, Xiao Li6*, Yicun Wang7, Qiujian Zheng1

1Department of Orthopedics, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China; 2State Key Laboratory of Chemistry for Life Science & Jiangsu Key Laboratory of Molecular Medicine, Medical School of Nanjing University, Nanjing 210093, China; 3Metrowest Medical Center, Framingham, MA, USA; 4Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China; 5Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China; 6Department of Urologic Surgery, Affiliated Cancer Hospital of Jiangsu Province of Nanjing Medical University, Nanjing 210009, China; 7Department of Orthopedics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, China

*Written on behalf of the Academic Made Easy, Excellent and Enthusiastic (AME) Collaborative Group

Correspondence to: Qiujian Zheng. Department of Orthopedics, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China. Email: zhengqiujian_GGH@163.com.

Received: 10 August 2017; Accepted: 10 August 2017; Published: 25 August 2017.

doi: 10.21037/amj.2017.08.15

Since 2015, the Chinese health-care system reforms have been emphasizing the importance of constructing hierarchical medical system. Hierarchical medical system policy was aimed to enhance the development of primary medical care and redistribute medical resources more rationally. At present, most of patients prefer to go to tertiary hospitals, which increases the working load on doctors there.

Although these extra burdens on doctors have been realized, no corresponding action has been taken. At the same time, it has been noticed that the rate of sudden death of doctors has been increasing in the past five years (Figure 1). On 26th July, 2017, a 30-year-old anesthetist died suddenly on his night shift in a tertiary hospital in China. He was the 14th doctors who had sudden death in 2017 (Table 1). According to systematic search of public reports on local media, medical websites and official documents, 45 doctors are found to be killed by sudden death since 2012. The majority of the doctors worked in tertiary hospitals. Most of them are surgeons or anesthetists (Table 1, Figure 1). Filled with tension and pressure, Chinese doctors are under a high risk of sudden death.

Figure 1 The characteristics of enrolled 45 Chinese doctors who killed by sudden death since 2012. (A) The number of doctors killed by sudden death since 2012 every year; (B) the distribution of department of affected doctors; (C) the proportion of doctors who worked more than 12 hours before sudden death; (D) the bar chart of affected doctors sorted by age; (E) the gender distribution of affected doctors; (F) the distribution of hospital of affected doctors; (G) the medical titles distribution of affected doctors; (H) the education background distribution of affected doctors; (I) the cause of sudden death of affected doctors; (J,K) the regional distribution of affected doctors in map (J) and in bar graph (K).

Table 1

General characteristics of enrolled doctors

ID Time of sudden death Age (years) Gender Province Levels of hospital Department Medical title Education background Cause of sudden death Brief description before sudden death
P01 2012/11/23 35 M Anhui Tertiary Orthopaedics Attending Doctoral Degree Heart attack He only had 3–4 hours for sleep every day and need to do research after works. He had a 24-hour shift before sudden death
P02 2013/07/05 50 F Jiangsu Tertiary Gastroenterology Associate of Chief Master’s Degree Undiagnosed She had more than 100 outpatients to receive every day
P03 2013/12/01 49 M Beijing Tertiary Cardiac Surgery Chief Doctoral Degree Cerebral hemorrhage The annual number of surgery is more than 300 for the last 5 years. Have the history of hypertension and hydrops articuli. He was giving emergency treatment to patient before sudden death
P04 2014/1/18 32 M Anhui Tertiary Anesthesiology Attending Doctoral Degree Undiagnosed He worked 6 days a week and more 12 hours every day. He did overtime work before sudden death.
P05 2014/09/20 48 M Beijing Tertiary Neurology Unavailable Unavailable Undiagnosed He was attending meeting before sudden death
P06 2014/10/12 55 M Beijing Tertiary Burns Surgery Chief Doctoral Degree Heart attack He had night shift in ICU before sudden death
P07 2014/10/25 48 M Beijing Tertiary Orthopaedics Associate of Chief Doctoral Degree Heart attack He was the specialist in bone tumor as well as the vice director of education department in hospital. He was attending an International Meeting in Thailand before sudden death
P08 2014/11/22 53 M Beijing Tertiary Orthopaedics Chief Doctoral Degree Undiagnosed He was the specialist in minimally invasive techniques for spinal surgery and worked over 8 hours every day. He was organizing a Conference before sudden death
P09 2014/12/02 42 M Beijing Tertiary Anesthesiology Associate of Chief Doctoral Degree Brainstem hemorrhage He was performing an operation before sudden death
P10 2015/01/11 47 M Guangdong Tertiary Orthopaedics Chief Doctoral Degree Cerebral hemorrhage The annual number of surgery is more than 300. He was on the way to surgery when sudden death happened
P11 2015/03/01 26 F Zhejiang Tertiary Anesthesiology Intern Bachelor Degree Undiagnosed She had a night shift before sudden death
P12 2015/03/02 28 M Shanxi Tertiary Psychiatry Resident Master's Degree Undiagnosed He had medical history of depression and had a night shift when sudden death happened
P13 2015/04/01 32 F Hunan Tertiary Anesthesiology Attending Bachelor Degree Undiagnosed She worked more 12 hours every day. He had a night shift when sudden death happened
P14 2015/04/13 48 M Beijing Tertiary Cardiac Surgery Associate of Chief Bachelor Degree Undiagnosed He had medical history of diabetes and hypertension. He worked continuously for several days before sudden death
P15 2015/04/14 51 M Fujian Tertiary Pediatrics Chief Doctoral Degree Cerebral hemorrhage He had a 24-hour shift every 3 days and only had 1 day off every 3 weeks
P16 2015/06/29 43 M Guangdong Tertiary Emergency Chief Doctoral Degree Cardiac rupture He had a 48-hour shift in the latest holiday. He had another 24-hour shift before sudden death
P17 2015/07/09 31 M Beijing Tertiary ICU Resident Doctoral Degree Heart attack He had only 3–4 hours for sleep every day and the rest time was always working
P18 2015/08/01 53 M Henan Tertiary Neurology Chief Master's Degree Myocardial infarction Unavailable
P19 2015/08/01 45 M Hubei Secondary Orthopaedics Associate of Chief Master's Degree Brainstem hemorrhage He had a 24-hour shift before sudden death
P20 2015/08/16 51 M Beijing Tertiary Orthopaedics Associate of Chief Doctoral Degree Heart attack He was a specialist in spine surgery and held several academic posts. He was in an academic conference when the sudden death happened
P21 2015/10/05 48 F Zhejiang Tertiary Stomatology Chief Doctoral Degree Cerebral hemorrhage Unavailable
P22 2015/10/11 37 M Henan Tertiary Neurosurgery Intern Bachelor Degree Undiagnosed Unavailable
P23 2016/01/02 45 F Liaoning Tertiary Pathology Associate of Chief Master's Degree Heart attack She was doing extra work in weekend when the sudden death happened
P24 2016/03/09 34 M Beijing Tertiary Anesthesiology Intern Bachelor Degree Undiagnosed He was in a night shift when the sudden death happened
P25 2016/04/21 35 M Anhui Secondary Orthopaedics Attending Bachelor Degree Undiagnosed He was on the way to an emergency operation before sudden death
P26 2016/05/15 25 M Fujian Tertiary Surgery Resident Bachelor Degree Undiagnosed Unavailable
P27 2016/06/30 45 M Guangdong Tertiary Orthopaedics Chief Doctoral Degree Undiagnosed He performed operation late into midnight two days before sudden death
P28 2016/08/16 49 M Shanghai Tertiary Traditional Chinese medicine Chief Doctoral Degree Undiagnosed He was a specialist in massage and held several academic posts. He kept received outpatients when he felt ill
P29 2016/09/21 45 M Anhui Tertiary Oncological Surgery Associate of Chief Master's Degree Heart attack He operated for 24 hours before sudden death
P30 2016/12/07 43 M Fujian Tertiary Hematology Associate of Chief Master's Degree Aortic dissection Unavailable
P31 2016/12/08 40 M Fujian Tertiary Pneumology Chief Doctoral Degree Heart attack Unavailable
P32 2017/01/09 27 M Xinjiang Secondary Anesthesiology Unavailable Unavailable Undiagnosed He had a 48-hour shift before sudden death
P33 2017/02/10 39 M Hebei Secondary Unavailable Unavailable Unavailable Undiagnosed He had a 24-hour shift before sudden death
P34 2017/03/27 25 M Jiangsu Secondary Anesthesiology Intern Unavailable Undiagnosed Unavailable
P35 2017/04/05 37 M Guangxi Tertiary Hepatic Surgery Attending Doctoral Degree Heart attack He needed to perform operation in working time and do academic research after work
P36 2017/04/16 30 M Guangxi Tertiary Traditional Chinese medicine Intern Unavailable Undiagnosed Unavailable
P37 2017/05/06 34 F Guangdong Tertiary Gastroenterology Attending Doctoral Degree Undiagnosed Unavailable
P38 2017/05/10 37 M Shandong Tertiary Surgery Associate of Chief Master's Degree Undiagnosed He had to work even if he was ill. He performed 5 operations before sudden death
P39 2017/06/10 44 M Zhejiang Tertiary Orthopaedics Associate of Chief Doctoral Degree Heart attack He had a 24-hour shift every 3 days and only had 1 day off every 3 weeks
P40 2017/06/28 26 M Zhejiang Tertiary Anesthesiology Intern Bachelor Degree Undiagnosed He had a 24-hour shift before sudden death
P41 2017/07/09 32 M Jiangxi Tertiary Orthopaedics Attending Doctoral Degree Heart attack He had a 24-hour shift before sudden death
P42 2017/07/09 44 M Sichuan Tertiary Pneumology Chief Doctoral Degree Undiagnosed He worked more than 10 hours every day and had a night shift before sudden death
P43 2017/07/18 36 M Henan Secondary Urinary Surgery Attending Unavailable Undiagnosed He had a night shift and continued to perform two operations before sudden death
P44 2017/07/20 41 M Tibet Tertiary Oncology Associate of Chief Unavailable Undiagnosed Unavailable
P45 2017/7/26 30 M Sichuan Tertiary Anesthesiology Attending Unavailable Undiagnosed He was in a night shift when the sudden death happened

This phenomenon may be largely due to lack of enough medical resources and its uneven distribution. China is a big country with 22% of world’s total population while it occupies only 2% of world’s medical resources (1). China only owns less than half of medical resources per capita (1.2 physicians/1,000 population vs. 2.8 physicians/1,000 population) compared with developed countries (1). All these factors contribute to the increasing burden on Chinese doctors in general. Moreover, since the access for a physician is not as strict as in western countries, patients are tended to tertiary hospitals for seeking better medical care (2). Including the large number of patients transferred from community hospitals, doctors in tertiary hospitals faced an extremely heavy burden in both outpatients and inpatients. Among the 45 doctors who had sudden death since 2012, 86% of them were from tertiary hospitals and 49% of them had been worked more than 12 hours before sudden death (Figure 1). In 2015, 2,402 doctors were enrolled in a survey which was conducted by Ding Xiang Yuan (the most popular biomedical website in China) (3). The survey showed that only 3% of doctors had less than 40 hours of working time every week while 37% of doctors had more than 60 hours to work every week (Figure 2). In addition, 47% of doctors had less than 1 day for rest every week (Figure 2) and 75% of them never had time for paid leave (Figure 2).

Figure 2 The survey on working status of Chinese doctors conducted by Ding Xiang Yuan in 2015 (n=2,402). (A) The distribution of working time per week. (B) the distribution of rest time per week; (C) the time for paid leave; (D) the distribution of activities in the rest time; (E) the frequency of feeling tired; (F) the distribution of treatment when feeling uncomfortable; (G) the distribution of hospital of enrolled interviewee; (H) the medical titles of enrolled interviewee; (I) the frequency of interval for night shift; (J) the number of patients received in outpatients half a day; (K) the surgery time of surgery on operation day; (L) the distribution of rest time in Spring Festival and National Day.

Getting promotion is another big challenge for Chinese doctors, especially in tertiary hospitals. Having National Natural Science Foundation and published paper listed in the Science Citation Index (SCI) are the criteria for candidates (4). As a result, doctors had to spend extra time on researches. As showed in Ding Xiang Yuan survey (3), study occupies almost all their time after work (Figure 2). Living in such conditions, half of doctors feel overwhelmed (Figure 2), but half of them would do no treatment when they felt uncomfortable (Figure 2).

The hierarchical medical system is an ideal method which is supposed to solve the problems above. However, it failed to cover the problems as follows: First, more medical resources should be created to relieve the extreme lack of total medical resources in China. Second, the quality of medical service in primary hospitals should been improved and the communication network among primary, secondary and tertiary hospitals should been well-rounded and timely, to ensure that patients could receive equal medical care. Third, the financial support from the government should been strengthened, especially for tertiary hospitals. It can relieve the pressure for hospitals to generate income as well as to reduce the competition among primary, secondary and tertiary hospitals (5). If only taken all these into consideration, would the current situation be changed.

Acknowledgements

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Medical Journal. The article did not undergo external peer review.

Conflicts of Interest: The authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/amj.2017.08.15). Zhantao Deng serves as an unpaid section editor of AME Medical Journal. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

  1. Shan HP, Yang XH, Zhan XL, et al. Overwork is a silent killer of Chinese doctors: a review of Karoshi in China 2013-2015. Public Health 2017;147:98-100. [Crossref] [PubMed]
  2. Huang J, Yan L, Zeng Y. Facing up to the threat in China. Lancet 2010;376:1823. [Crossref] [PubMed]
  3. Available online: http://www.dxy.cn/
  4. Yuan HF, Xu WD, Hu HY. Young Chinese doctors and the pressure of publication. Lancet 2013;381:e4. [Crossref] [PubMed]
  5. Chinese doctors are under threat. Lancet 2010;376:657. [Crossref] [PubMed]
doi: 10.21037/amj.2017.08.15
Cite this article as: Deng Z, Jin J, Dai Q, Pan J, Wang X, Liu R, Li X, Wang Y, Zheng Q. Chinese doctors are under a high risk of sudden death. AME Med J 2017;2:125.

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