On Christmas Eve 2019, Dr. Yang Wen had two more hours on the night shift at a General Hospital in Beijing, and planned to spend the day with her college student son, who was back from Yale for the holidays. But an irate man, who had been complaining about his 95-year-old mother’s treatment, snapped. He suddenly started stabbing the doctor with a knife, which, in a matter of seconds, severed her windpipe and arteries, and broke her neck. Rather than a rare event, this incident reflects an alarming trend: the frequency of physicians being assaulted by patients has increased dramatically in the past two decades.

Falling from grace to violence

In many societies, Western or Eastern, the medical profession has been respected as a fundamental pillar of our life—constantly being ranked among the most prestigious occupations. However, according to a recent national survey in China, two thirds of hospitals reported physical attacks on physicians. Similarly, the medical association in India reported that three quarters of doctors faced verbal or physical abuse in workplace. Even in more developed countries such as the UK and Germany, recent surveys found that half of general practitioners had suffered abuse or violence. How and why did this dramatic fall from grace happen?

To answer this question, our recent paper explored a thirty-year period of contemporary Chinese history. We suggest that the stigmatisation of the medical profession in China is a three-phase process, triggered and catalysed by three distinct events. In the first phase, the marketisation of public health care since the mid-1980s had shifted the professional mandate from serving the people towards seeking profit. Influenced by the gradual reduction of public funding, hospitals began establishing incentive systems that would make doctors more cognisant of the need to generate revenues. Interestingly, however, the doctors’ overprescribing was not harshly criticised immediately. Instead, for a decade, the media had covered the profession with a relatively positive tone. Reports of aggressive behaviours by patients were sporadic—partially because the overprescribed medicine remained largely reimbursable through the public health insurance systems.

The second phase was triggered by the reforms in the public health insurance systems. Since the 1990s a growing number of cities and provinces in China had set up new health insurance systems, which covered medical expenses only partially. In other words, the doctors’ overprescription now inflicted direct, discernible financial damage to patients. Not only did patients start to express their dissatisfaction in a more aggressive way, the media also adopted a more negative tone reporting the doctors’ unethical behaviours. Moreover, through what we call “a spiral of voice,” patients and the media learned of how others were expressing their dissatisfaction—amplifying tensions and encouraging similar aggressive behaviours—which, in turn, pulled the government back in.

However, the government’s re-entrance only catalysed the process of stigmatisation as it highlighted the transgressive behaviours of medical professionals as a collective. Although the government might intend to suppress professional misconduct by public shaming, a widely used strategy to manage transgressions, it unintendedly shaped a momentum of collective disapproval by the media and patients. Surprisingly, however, our study shows that while the government, media, and patients collectively criticise the medical profession, they diverge in their prescriptions of appropriate punishment: patients inflict harsher and more violent punishment as they are directly harmed and cannot escape from their strong dependence on the profession.

Temporal respite

Despite the increasing vilification of doctors, we found two temporal respites. The first was provided by the 2002-2003 SARS epidemic, during which the medical profession was widely praised by the media for their commitment to saving patients’ lives—with some even being portrayed as martyrs after they fell victim to the epidemic. This recovery of professional respect, however, was short-lived. Once the epidemic was over, the media quickly resumed its highlighting of the unethical behaviours of doctors. The second respite is now occurring during the current COVID-19 pandemic. A public health crisis can immediately highlight the importance and devotion of doctors, but will the COVID-19 pandemic become an opportunity for the government and the profession to restore and sustain moral approval? We hope so.

Stigma: a problem facing more professions

While our study focuses on the medical profession, it speaks to a broader issue of the decline of confidence in professions. This is particularly timely given increasing reports of professional misbehaviour—such as the role of non-disclosure agreement lawyers in the Weinstein affair, of accountants in the failures of Enron and Thomas Cook, of financial analysts in the subprime crisis, and of police in the death of George Floyd—which cumulatively suggest that the risk of professions being stigmatised is becoming a more widespread phenomenon. Given that professions are basic societal institutions, any collapse of confidence in them may have profound consequences for social stability. It is, in this respect, a disquietingly neglected “grand challenge” that warrants further attention.

♣♣♣

Notes:


Milo Shaoqing Wang is a doctoral candidate at the University of Alberta. His current research examines the process by which organisations strategically translate and transplant contested practices into an alien environment where the practices challenge existing institutions. He is interested in the intersection of social evaluation, strategic management, and institutional theory.

 

Mia Raynard is an assistant professor of organisational change in the management department at Vienna University of Economics and Business. Her research examines processes of change that unfold at the organisation and field levels, and responses to conflicting pressures for change and stability. Her recent work focuses on emerging markets, professions, and CSR and sustainability.

 

Royston Greenwood is Professor Emeritus at the University of Alberta, and professorial fellow at the University of Edinburgh Business School. He received his PhD from the University of Birmingham in the UK. He is a fellow of the Academy of Management and an honorary member of the European Group for Organization Studies (EGOS). His current work focuses upon the application of institutional analysis to social issues—such as corruption and wrongdoing—in professional contexts.