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Call for shared decision making in China: Challenges and opportunities
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Call for Shared Decision Making in China: Challenges and Opportunities Aufruf zu partizipativer Entscheidungsfindung in China: Herausforderungen und Chancen Mi Yao a,b , Samuel Finnikin c,∗ , K.K. Cheng a,c a
Department of General Practice, Peking University Health Science Center, Beijing, China Beijing Xicheng District Xinjiekou Community Health Service Center, Beijing, China c Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK b
a r t i c l e
i n f o
Available online: xxx
Keywords: shared decision making chinese healthcare doctor patient relationships
a r t i k e l
i n f o
Online gestellt: xxx
Schlüsselwörter: partizipative Entscheidungsfindung chinesische Gesundheitssystem Arzt-Patient-Beziehung
a b s t r a c t China’s healthcare system has undergone extensive changes over recent years and the most recent reforms are designed to shift the emphasis away from hospital based services towards a more primary care based system. There is an increasing recognition that shared decision making needs to play a central role in the delivery of healthcare in China, but there are several significant barriers to overcome before this aspiration becomes a reality. Doctor-patient relationships in China are poor, consultations are often brief transactions and levels of trust are low. Implementing a shared decision making process developed in the Western World may be hampered by cultural differences, although this remains an under-researched area. There is, however, a suggestion that the academic community are starting to take an interest in encouraging shared decision making in practice and indications that the Chinese public may be willing to consider this new approach to healthcare.
z u s a m m e n f a s s u n g Das chinesische Gesundheitssystem hat sich im Laufe der letzten Jahre stark gewandelt; die jüngsten Reformen sollen den Schwerpunkt von einer krankenhausbasierten Versorgung hin zu einem stärker auf dem Konzept der Primärversorgung beruhenden System verlagern. Die Erkenntnis wächst, dass partizipative Entscheidungsfindung in der chinesischen Gesundheitsversorgung eine zentrale Rolle wird spielen müssen, doch bevor sich diese Bestrebungen realisieren lassen, gilt es, einige wesentliche Hürden zu überwinden. Um die Arzt-Patient-Beziehung ist es in China schlecht bestellt; der Arztbesuch ist häufig eine kurze Angelegenheit mit niedrigem Vertrauensniveau. Die Implementierung des Prozesses der partizipativen Entscheidungsfindung, wie er in der westlichen Welt entwickelt wurde, könnte aufgrund der kulturellen Unterschiede auf Schwierigkeiten stoßen, wobei dieses Thema bislang allerdings noch unzureichend erforscht ist. Es gibt jedoch Hinweise darauf, dass die akademische Community sich für die Förderung von partizipativer Entscheidungsfindung in der Praxis zu interessieren beginnt, und auch Anhaltspunkte dafür, dass die chinesische Öffentlichkeit möglicherweise bereit ist, über diese neue Herangehensweise an die Gesundheitsversorgung nachzudenken.
∗ Corresponding author: Dr Samuel Finnikin; Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. E-mail: fi[email protected] (S. Finnikin). http://dx.doi.org/10.1016/j.zefq.2017.05.004 1865-9217/
Please cite this article in press as: Yao M, et al. Call for Shared Decision Making in China: Challenges and Opportunities. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.05.004
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An overview of Medical and Health Services in China There are four important stages in the development of China’s healthcare. Between 1949 and 1984, the government owned and operated all healthcare facilities and employed the healthcare workforce. In this system, China used community health workers to provide basic public and personal health services at the village level. In the 1980s, the Chinese government initiated a major reform of the medical and healthcare systems. The role of the government in healthcare was dramatically reduced and a free-market approach was adopted. However, most of the population remained uninsured and therefore people were suddenly exposed to the full burden of healthcare costs [1]. In 2009, China launched reforms that accomplished nearly universal insurance coverage, especially in rural areas [2,3]. In addition, new medical and healthcare systems were implemented [4]. Firstly, a public health service was established. This is responsible for disease prevention and control, health education, maternity and child care, and a medical and healthcare system based on communitylevel healthcare networks. The second tier service is the medical care system. In the rural areas, this refers to a three-level medical service network that consists of the county hospital, the township hospitals and village clinics. In the cities and towns, a new type of urban medical health service system was established that features division of responsibilities as well as cooperation among various types of hospitals at all levels and community healthcare centers. During this period, government investments in healthcare infrastructure and activities were heavily concentrated in hospitals. This resulted in rapid improvements in secondary and tertiary care in China, but has also created new problems [5]. A heavy focus on more expensive healthcare resulted in problems of affordability, over-investigations, over-treatment, uncoordinated healthcare provision, and associated increased tensions in doctor-patient relationships [6] as well as declining interest among school leavers to pursue a medical career [7]. In 2015, in recognition of these problems, the National Health and Family Planning Commission of the People’s Republic of China set out their plans for the future of healthcare [8]. Local authorities were tasked with optimizing medical resources by restructuring systems to reverse the over reliance on hospital care and strengthen primary care. These changes are due to be fully implemented by 2020.
Doctor-Patient Relationships Structural imbalances and ongoing system transformation have had an important effect on the doctor-patient relationship. A large, national survey in 2008 found that 80% of medical professionals considered the doctor-patient relationship to be poor or very poor [9]. An unfortunate manifestation of this is seen in the large number of violent incidents perpetrated against doctors. One survey in 2012 found that 96% of medical staff reported abuse or injury [10] and concerns over violence are a major source of low job satisfaction amongst Chinese doctors [6]. Violence towards healthcare workers is an extreme demonstration of the mistrust that exists between patients and doctors [11]. This mistrust stems from patient perceptions of injustice within the healthcare system and concerns over the inherent knowledge imbalance that exists [12,13]. However, when the doctor-patient relationship is examined from the perspective of patients a more positive view has been found, with 67% of patients reporting that they trust or strongly trust physicians [13]. Whilst there has been unprecedented economic grown in China over the past three decades, health literacy amongst patients has
not improved at the same rate and most patients regard healthcare services as commercial transactions [14]. This exacerbates the knowledge imbalance between patients and doctors which is a major contributing factor to the mistrust that exists in this relationship. Against this background, shared decision making is a mechanism that has the potential help to decrease the informational and power asymmetry between doctors and patients [15] and as such should be seen as an important aspect of restoring trust in the Chinese healthcare system. However, shared decision making can only be built on a foundation of trust and mutual respect [16]. So whilst shared decision making may improve trust, implementing this in practice may be difficult without other strategies to promote trust in the system. Rebuilding trust will require a concerted effort involving changes in medical education, healthcare system, legal and ethical systems, and public education [17].
Shared Decision Making in China In 2015, a review by Huang et al searched multiple sources for evidence of shared decision making in China, but could not find any sign of the development, testing, or implementation of shared decision making tools for patients in Mainland China [18]. They concluded that shared decision making may be out of China’s reach in the current environment due to insufficiencies and inequities in the healthcare delivery system, low health literacy of the Chinese populations, extremely brief clinical encounters, and the state of distrust and disrespect between patients and clinicians. This review included the literature up to 2014. To update this, we searched several Chinese databases and media reports from 2014 to 2017. Huang and colleagues have gone on to demonstrate the feasibility of using a decision aid (the Statin Choice decision aid) to implement shared decision making in a referral cardiology practice in China [19] and further research is planned [20]. Other clinical areas are also demonstrating an interest in shared decision making. In colorectal cancer, 60% of patients prefer to be actively involved in the decision making process [21]. Another research group showed that shared decision making was effective in boosting treatment compliance and efficacy amongst Chinese patients with schizophrenia resulting in improved social functioning and reduced relapse rates [22]. Several other papers have been published on the theoretical aspects of SDM which demonstrates an academic interest in this area [23–26]. Some shared decision making questionnaires, such as the OPTION scale and the SDM-Q-9 have been translated into Chinese [27,28]. However, only OPTION is in Simplified Chinese (used in mainland China). Validation studies have not been undertaken and there is no research using these tools in mainland China. A conference about shared decision making, that is widely thought to be the very first such meeting in China, was held in Beijing on June 24th , 2015 and this attracted considerable media interest [29]. Chinese and overseas delegates at this conference agreed on the value of shared decision making but also identified several challenges faced in changing current practice, not least the fact that many clinical consultations currently only last 2-3 minutes. The conference was also ranked by the website of Xinhua News Agency (the official press agency of China and also China’s biggest and most influential media organization) as the event that had made the greatest constructive contribution to improving doctor-patient relationship in China in 2015 [30]. However, it is very clear that there is still a long journey to travel before shared decision making can start to take root in China. We anticipate considerable challenges and difficulties in the journey.
Please cite this article in press as: Yao M, et al. Call for Shared Decision Making in China: Challenges and Opportunities. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.05.004
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Cultural Considerations Shared decision making is a paradigm that has been developed and refined largely in the context of Western society. It is questionable to assume that this can be simply transposed onto the Chinese Culture. We must consider the cultural challenges associated with engaging Chinese patients in shared decision making in order to make this technique meaningful to patients [31]. The traditional Chinese culture is based on diverse and competing philosophies founded in Confucianism. Within such a system of cultural values, people often rely on accumulated wisdom, precedent, and intuition rather than on reasons and objectivity [32]. Also, many are passive, superstitious and fatalist by nature, often believing that destiny, luck, and circumstance are more important than personal action. This philosophical outlook could be a huge barrier to widespread acceptance of shared decision making by Chinese patients. Additionally, the role of the extended family in decision making is a particular feature in contemporary Chinese society [19,21]. Overlooking this would compromise efforts to implement shared decision making. Given the general cultural themes outlined above, one might expect Chinese people to be adverse to uncertainty. Although it can be difficult to compare cultures directly, extensive work looking into how workplace values are influenced by culture has been undertaken by the Dutch population biologist and social scientist Geert Hofstede. This research has produced a series of ‘Cultural Dimensions’ for over 70 countries worldwide which, amongst other things, expresses the degree to which the members of a society feel uncomfortable with uncertainty and ambiguity. This reveals that China actually has a similar uncertainty avoidance score to the United States and the United Kingdom with all three countries being relatively comfortable with uncertainty [33]. In healthcare, certainty is an illusion [34] and an ability to tolerate uncertainty is vital to modern healthcare systems. China’s ability to tolerate uncertainty may facilitate the adoption of shared decision making. Additionally, survey data suggests that there may be willingness amongst Chinese patients to get involved in their medical care and to be better informed about their medical problems. However, the lack of time in consultations and a mismatch between doctor and patient perceptions have been identified as major barriers for effective communication and decision making [35–37].
Barriers to Shared Decision Making in China In addition to the general cultural considerations outlined above, there are specific aspects of the medical system in China that may impede adoption of shared decision making. Firstly, there is a lack of appreciation for medical humanities in Chinese medical society. This results in limited recognition of the importance of patient-centered care and the principals of medical ethics amongst medical students and staff. Therefore the values that underpin the foundations of shared decision making are deficient. It has also been argued that the fee-for-service model in China makes it difficult for patients to receive unbiased information and therefore shared decision making is impeded [38]. In order to embed shared decision making into a healthcare system, it is important that clinicians have appropriate tools available to them [39]. In China, these tools and systems are lacking. The situation with cancer screening provides an illustrative case study. The ‘‘Cancer Prevention and Treatment three-year Action Plan’’ [40] recommends population screening for lung, liver, gastric, esophageal, colorectal, breast and cervical cancer and screening rates are increasing [41]. National cancer screening guidelines encourage shared decision making, thus demonstrating a willingness to incorporate this process into clinical practice at a policy
3
level [42]. However, this sentiment has not been backed up with practical support as guidelines do not include a specific implementation plan or provide any tools to aid shared decision making. As a result, we believe that few doctors in China practice shared decision making with patients or discuss the pros, cons, and uncertainties of screening. This may be because many health professionals involved in cancer screening do not have clear ideas of potential benefits and harms. Similarly, substantial proportion of the population in China have an ‘‘annual physical’’ in various healthcare organizations, but little information about the effects of these annual checkups are provided to them and there is no evidence to suggest that shared decision making is integral to the process. The future of Shared Decision Making in China The successful implementation of shared decision making in China could present a substantial challenge. Although there are an abundance of tools to aid shared decision making internationally, to adapt these for China and evaluate their uses will require time and resources, as well as commitments from relevant organisations. There would also be a need for research on the acceptability, long-term effectiveness and costs of patient decision aids in China. Implementation of decision aids would have to be done in conjunction with a concerted effort to train existing and new clinicians in the skills required to engage patients in meaningful discourse. Furthermore, healthcare services will need to be designed to facilitate and promote shared decision making in a variety of settings. There is much to be done, and a long journey to travel, before shared decision making becomes accepted as the normal way of making health decisions in China. Conflict of Interest None declared. References [1] Blumenthal D, Hsiao W. Lessons from the East—China’s rapidly evolving health care system. New England Journal of Medicine 2015;372(14):1281–5. [2] Wang C, Rao K, Wu S, Liu Q. Health care in China: improvement, challenges, and reform. CHEST Journal 2013;143(2):524–31. [3] Yip WC-M, Hsiao WC, Chen W, Hu S, Ma J, Maynard A. Early appraisal of China’s huge and complex health-care reforms. The Lancet 2012;379(9818):833–42. [4] Information Office of the State Council. A White Paper on Medical and Health Services in China: Information Office of the State Council The People’s Republic of China,; 2012 [03.04.2017]. Available from: http://english.gov.cn/ archive/white paper/2014/08/23/content 281474982986476.htm. [5] Meng Q, Xu L, Zhang Y, Qian J, Cai M, Xin Y, et al. Trends in access to health services and financial protection in China between 2003 and 2011: a crosssectional study. The Lancet 2012;379(9818):805–14. [6] Wu D, Wang Y, Lam KF, Hesketh T. Health system reforms, violence against doctors and job satisfaction in the medical profession: a cross-sectional survey in Zhejiang Province, Eastern China. BMJ open 2014;4(12):e006431. [7] Lien SS, Kosik RO, Fan AP, Huang L, Zhao X, Chang X, et al. 10-year trends in the production and attrition of Chinese medical graduates: an analysis of nationwide data. The Lancet 2016;388:S11. [8] PRC NHaFPCot. China sets up new system to optimize medical resources 2015 [03.04.2017]. Available from: http://en.nhfpc.gov.cn/201509/16/c 46816.htm. [9] Zhang X, Sleeboom-Faulkner M. Tensions between medical professionals and patients in mainland China. Cambridge Quarterly of Healthcare Ethics 2011;20(03):458–65. [10] Jia X, Zhou H, Zhao Y, Zheng L, Wei Q, Zheng X. Investigation on hospital violence 2003-2012 in China. Chinese Hospitals 2014;(18):1–3. [11] Shan L, Li Y, Ding D, Wu Q, Liu C, Jiao M, et al. Patient Satisfaction with Hospital Inpatient Care: Effects of Trust, Medical Insurance and Perceived Quality of Care. PloS one 2016;11(10):e0164366. [12] Tucker JD, Cheng Y, Wong B, Gong N, Nie J-B, Zhu W, et al. Patient–physician mistrust and violence against physicians in Guangdong Province, China: a qualitative study. BMJ open 2015;5(10):e008221. [13] Zhao D-H, Rao K-Q, Zhang Z-R. Patient trust in physicians: empirical evidence from Shanghai. China. Chinese medical journal 2016;129(7):814.
Please cite this article in press as: Yao M, et al. Call for Shared Decision Making in China: Challenges and Opportunities. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.05.004
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[14] Lyu Z, Wu S, Cai Z, Guan X. Patient–physician trust in China: health education for the public. The Lancet 2016;388(10063):2991. [15] Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter what does it mean. Social Science Medicine 1997;44(5):681–92. [16] Roter D. The enduring and evolving nature of the patient–physician relationship. Patient education and counseling 2000;39(1):5–15. [17] Tucker JD, Wong B, Nie J-B, Kleinman A. Rebuilding patient-physician trust in China. The Lancet 2016;388(10046):755. [18] Huang R, Gionfriddo MR, Zhang L, Leppin AL, Ting HH, Montori VM. Shared decision-making in the People’s republic of china: current status and future directions. Patient preference and adherence 2015;9:1129. [19] Huang R, Song X, Wu J, Huang W, Leppin AL, Gionfriddo MR, et al. Assessing the feasibility and quality of shared decision making in china: evaluating a clinical encounter intervention for chinese patients. Patient preference and adherence 2016;10:2341. [20] Huang R-C, Ma S-M, Song X-t, Yang P, Liang B, Sun M, et al. Shared decision making between Chinese medical staff members and patients with coronary heart disease: study protocol for a multicenter, large sample, cross-sectional, openlabel, clinical survey. Clinical Trials in Degenerative Diseases 2016;1(4):166. [21] Hou X-T, Xu Z, Zhou Y-J, Lu Q, Pang D. Colorectal cancer patients’ participant roles during operation treatment decision making process:a cross-sectional study. Chinese Journal of Nursing 2014;49(5.). [22] Liang Q-S, Du Y, Pan J-E, Chen Y-Q. Influences of shared decision making on schizophrenic treatment compliance. Journal of Clinical psychosomatic diseases 2015;21(5):116–8. [23] Chen L. Advance in shared-decision-making by doctors, nurses and patients, Journal of Nursing Science. 2016;31(24):103–5. [24] Gao F, Zhao M-J. Review of Foreign Joint Decision-making between Doctors and Patients. Medicine & Philosophy 2016;37(2):1–4. [25] Zhu N. Physicians should be in a Dominant Position in Clinical Decision Making Based on Mutual Trust. Medicine & Philosophy 2015;36(12):21–3. [26] Liao S-F. Study on the Clinical Experience of Diagnosis and Treatment of Diabetes Club Patients with the Common Decision Model of Doctors and Patients. Diabetes New World 2016;19(5):197–8. [27] Elwyn G. OPTION 12 - Chinese version 2009 [18.04.2017]. Available from: http://www.optioninstrument.org/uploads/2/4/0/4/24040341/chinese version.pdf. [28] Härter M, Scholl I, Hou W-H, Liang H-W. SDM-9-Q Mandarin Chinese: Patient as parenter; 2017 [18.04.2017]. Available from: http://www.patientals-partner.de/media/sdm-q-doc mandarin.pdf.
[29] Freezing Point. Three fellows of the doctor patient relationship - an experiment: China Youth Daily; 2015 [27.03.2017]. Available from: http://zqb.cyol.com/html/2015-06/24/nw.D110000zgqnb 20150624 112.htm?from=groupmessage. [30] People - Health Channel. Rebuilding trust-2015 doctor-patient relationship rebuilding report 2015 [03.04.2017]. Available from: http://health. people.com.cn/n/2015/0924/c398004-27627962.html. [31] Hawley ST, Morris AM. Cultural challenges to engaging patients in shared decision making. Patient Education and Counseling 2017;100(1):18–24. [32] Khairullah D, Khairullah ZY. Cultural values and decision-making in China. [33] Hofstede G. The 6-D model of national culture [28.03.2017]. Available from: http://geerthofstede.com/culture-geert-hofstede-gert-jan-hofstede/6dmodel-of-national-culture/. [34] Simpkin AL, Schwartzstein RM. Tolerating uncertainty—the next medical revolution? New England Journal of Medicine 2016;375(18):1713–5. [35] Zhang Q WH, Dong X, Chen X, Wang F, Fan Z, Zhou Y, Liu Y, Wan X, Zhang M. A survey analysis of doctors’ and patients’ perceptions of shared decision making in China. Abstracts of the 17th Cochrane Colloquium. 2009. [36] Zhang M LG, Wang H, Chen X, Zhang Q, Wang F, Fan Z, Zhou Y. Barriers and concerns in patient perceptions of shared decision making in China. Evidence in the era of globalisation Abstracts of the 16th Cochrane Colloquium. 2008. [37] Zheng Y, Huang W, Xiao B, Qu B, Peng W, Liu B, et al. Preferences for participation in shared decision-making among cataract patients in urban southern China: a cross-sectional study. The Lancet 2016;388:S56. [38] Biao Xu. Shared decision making in China BMJ online: BMJ; 2010 [13.03.2017]. Available from: http://blogs.bmj.com/bmj/2010/12/23/biao-xushared-decision-making-in-china/. [39] Elwyn G, Laitner S, Coulter A, Walker E, Watson P, Thomson R. Implementing shared decision making in the NHS. BMJ 2010:341. [40] National Health and Family Planning Commission of the PRC. China’s cancer prevention and treatment three-year action plan (2015-2017) [28.03.2017]. Available from: http://en.nhfpc.gov.cn/20162016 01/08/c 68740.htm. [41] Zou X-N. Epidemic trend, screening, and early detection and treatment of cancer in Chinese population. Cancer Biology & Medicine 2017;14(1): 50–9. [42] Zhou QH, Fan YG, Bu H, Wang Y, Wu N, Huang YC, et al. China national lung cancer screening guideline with low-dose computed tomography (2015 version). Thoracic cancer 2015;6(6):812–8.
Please cite this article in press as: Yao M, et al. Call for Shared Decision Making in China: Challenges and Opportunities. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.05.004
ARTICLE IN PRESS
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Contents lists available at ScienceDirect
Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) journal homepage: http://www.elsevier.com/locate/zefq
Call for Shared Decision Making in China: Challenges and Opportunities Aufruf zu partizipativer Entscheidungsfindung in China: Herausforderungen und Chancen Mi Yao a,b , Samuel Finnikin c,∗ , K.K. Cheng a,c a
Department of General Practice, Peking University Health Science Center, Beijing, China Beijing Xicheng District Xinjiekou Community Health Service Center, Beijing, China c Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK b
a r t i c l e
i n f o
Available online: xxx
Keywords: shared decision making chinese healthcare doctor patient relationships
a r t i k e l
i n f o
Online gestellt: xxx
Schlüsselwörter: partizipative Entscheidungsfindung chinesische Gesundheitssystem Arzt-Patient-Beziehung
a b s t r a c t China’s healthcare system has undergone extensive changes over recent years and the most recent reforms are designed to shift the emphasis away from hospital based services towards a more primary care based system. There is an increasing recognition that shared decision making needs to play a central role in the delivery of healthcare in China, but there are several significant barriers to overcome before this aspiration becomes a reality. Doctor-patient relationships in China are poor, consultations are often brief transactions and levels of trust are low. Implementing a shared decision making process developed in the Western World may be hampered by cultural differences, although this remains an under-researched area. There is, however, a suggestion that the academic community are starting to take an interest in encouraging shared decision making in practice and indications that the Chinese public may be willing to consider this new approach to healthcare.
z u s a m m e n f a s s u n g Das chinesische Gesundheitssystem hat sich im Laufe der letzten Jahre stark gewandelt; die jüngsten Reformen sollen den Schwerpunkt von einer krankenhausbasierten Versorgung hin zu einem stärker auf dem Konzept der Primärversorgung beruhenden System verlagern. Die Erkenntnis wächst, dass partizipative Entscheidungsfindung in der chinesischen Gesundheitsversorgung eine zentrale Rolle wird spielen müssen, doch bevor sich diese Bestrebungen realisieren lassen, gilt es, einige wesentliche Hürden zu überwinden. Um die Arzt-Patient-Beziehung ist es in China schlecht bestellt; der Arztbesuch ist häufig eine kurze Angelegenheit mit niedrigem Vertrauensniveau. Die Implementierung des Prozesses der partizipativen Entscheidungsfindung, wie er in der westlichen Welt entwickelt wurde, könnte aufgrund der kulturellen Unterschiede auf Schwierigkeiten stoßen, wobei dieses Thema bislang allerdings noch unzureichend erforscht ist. Es gibt jedoch Hinweise darauf, dass die akademische Community sich für die Förderung von partizipativer Entscheidungsfindung in der Praxis zu interessieren beginnt, und auch Anhaltspunkte dafür, dass die chinesische Öffentlichkeit möglicherweise bereit ist, über diese neue Herangehensweise an die Gesundheitsversorgung nachzudenken.
∗ Corresponding author: Dr Samuel Finnikin; Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. E-mail: fi[email protected] (S. Finnikin). http://dx.doi.org/10.1016/j.zefq.2017.05.004 1865-9217/
Please cite this article in press as: Yao M, et al. Call for Shared Decision Making in China: Challenges and Opportunities. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.05.004
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ARTICLE IN PRESS M. Yao et al. / Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) xxx (2017) xxx–xxx
2
An overview of Medical and Health Services in China There are four important stages in the development of China’s healthcare. Between 1949 and 1984, the government owned and operated all healthcare facilities and employed the healthcare workforce. In this system, China used community health workers to provide basic public and personal health services at the village level. In the 1980s, the Chinese government initiated a major reform of the medical and healthcare systems. The role of the government in healthcare was dramatically reduced and a free-market approach was adopted. However, most of the population remained uninsured and therefore people were suddenly exposed to the full burden of healthcare costs [1]. In 2009, China launched reforms that accomplished nearly universal insurance coverage, especially in rural areas [2,3]. In addition, new medical and healthcare systems were implemented [4]. Firstly, a public health service was established. This is responsible for disease prevention and control, health education, maternity and child care, and a medical and healthcare system based on communitylevel healthcare networks. The second tier service is the medical care system. In the rural areas, this refers to a three-level medical service network that consists of the county hospital, the township hospitals and village clinics. In the cities and towns, a new type of urban medical health service system was established that features division of responsibilities as well as cooperation among various types of hospitals at all levels and community healthcare centers. During this period, government investments in healthcare infrastructure and activities were heavily concentrated in hospitals. This resulted in rapid improvements in secondary and tertiary care in China, but has also created new problems [5]. A heavy focus on more expensive healthcare resulted in problems of affordability, over-investigations, over-treatment, uncoordinated healthcare provision, and associated increased tensions in doctor-patient relationships [6] as well as declining interest among school leavers to pursue a medical career [7]. In 2015, in recognition of these problems, the National Health and Family Planning Commission of the People’s Republic of China set out their plans for the future of healthcare [8]. Local authorities were tasked with optimizing medical resources by restructuring systems to reverse the over reliance on hospital care and strengthen primary care. These changes are due to be fully implemented by 2020.
Doctor-Patient Relationships Structural imbalances and ongoing system transformation have had an important effect on the doctor-patient relationship. A large, national survey in 2008 found that 80% of medical professionals considered the doctor-patient relationship to be poor or very poor [9]. An unfortunate manifestation of this is seen in the large number of violent incidents perpetrated against doctors. One survey in 2012 found that 96% of medical staff reported abuse or injury [10] and concerns over violence are a major source of low job satisfaction amongst Chinese doctors [6]. Violence towards healthcare workers is an extreme demonstration of the mistrust that exists between patients and doctors [11]. This mistrust stems from patient perceptions of injustice within the healthcare system and concerns over the inherent knowledge imbalance that exists [12,13]. However, when the doctor-patient relationship is examined from the perspective of patients a more positive view has been found, with 67% of patients reporting that they trust or strongly trust physicians [13]. Whilst there has been unprecedented economic grown in China over the past three decades, health literacy amongst patients has
not improved at the same rate and most patients regard healthcare services as commercial transactions [14]. This exacerbates the knowledge imbalance between patients and doctors which is a major contributing factor to the mistrust that exists in this relationship. Against this background, shared decision making is a mechanism that has the potential help to decrease the informational and power asymmetry between doctors and patients [15] and as such should be seen as an important aspect of restoring trust in the Chinese healthcare system. However, shared decision making can only be built on a foundation of trust and mutual respect [16]. So whilst shared decision making may improve trust, implementing this in practice may be difficult without other strategies to promote trust in the system. Rebuilding trust will require a concerted effort involving changes in medical education, healthcare system, legal and ethical systems, and public education [17].
Shared Decision Making in China In 2015, a review by Huang et al searched multiple sources for evidence of shared decision making in China, but could not find any sign of the development, testing, or implementation of shared decision making tools for patients in Mainland China [18]. They concluded that shared decision making may be out of China’s reach in the current environment due to insufficiencies and inequities in the healthcare delivery system, low health literacy of the Chinese populations, extremely brief clinical encounters, and the state of distrust and disrespect between patients and clinicians. This review included the literature up to 2014. To update this, we searched several Chinese databases and media reports from 2014 to 2017. Huang and colleagues have gone on to demonstrate the feasibility of using a decision aid (the Statin Choice decision aid) to implement shared decision making in a referral cardiology practice in China [19] and further research is planned [20]. Other clinical areas are also demonstrating an interest in shared decision making. In colorectal cancer, 60% of patients prefer to be actively involved in the decision making process [21]. Another research group showed that shared decision making was effective in boosting treatment compliance and efficacy amongst Chinese patients with schizophrenia resulting in improved social functioning and reduced relapse rates [22]. Several other papers have been published on the theoretical aspects of SDM which demonstrates an academic interest in this area [23–26]. Some shared decision making questionnaires, such as the OPTION scale and the SDM-Q-9 have been translated into Chinese [27,28]. However, only OPTION is in Simplified Chinese (used in mainland China). Validation studies have not been undertaken and there is no research using these tools in mainland China. A conference about shared decision making, that is widely thought to be the very first such meeting in China, was held in Beijing on June 24th , 2015 and this attracted considerable media interest [29]. Chinese and overseas delegates at this conference agreed on the value of shared decision making but also identified several challenges faced in changing current practice, not least the fact that many clinical consultations currently only last 2-3 minutes. The conference was also ranked by the website of Xinhua News Agency (the official press agency of China and also China’s biggest and most influential media organization) as the event that had made the greatest constructive contribution to improving doctor-patient relationship in China in 2015 [30]. However, it is very clear that there is still a long journey to travel before shared decision making can start to take root in China. We anticipate considerable challenges and difficulties in the journey.
Please cite this article in press as: Yao M, et al. Call for Shared Decision Making in China: Challenges and Opportunities. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.05.004
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Cultural Considerations Shared decision making is a paradigm that has been developed and refined largely in the context of Western society. It is questionable to assume that this can be simply transposed onto the Chinese Culture. We must consider the cultural challenges associated with engaging Chinese patients in shared decision making in order to make this technique meaningful to patients [31]. The traditional Chinese culture is based on diverse and competing philosophies founded in Confucianism. Within such a system of cultural values, people often rely on accumulated wisdom, precedent, and intuition rather than on reasons and objectivity [32]. Also, many are passive, superstitious and fatalist by nature, often believing that destiny, luck, and circumstance are more important than personal action. This philosophical outlook could be a huge barrier to widespread acceptance of shared decision making by Chinese patients. Additionally, the role of the extended family in decision making is a particular feature in contemporary Chinese society [19,21]. Overlooking this would compromise efforts to implement shared decision making. Given the general cultural themes outlined above, one might expect Chinese people to be adverse to uncertainty. Although it can be difficult to compare cultures directly, extensive work looking into how workplace values are influenced by culture has been undertaken by the Dutch population biologist and social scientist Geert Hofstede. This research has produced a series of ‘Cultural Dimensions’ for over 70 countries worldwide which, amongst other things, expresses the degree to which the members of a society feel uncomfortable with uncertainty and ambiguity. This reveals that China actually has a similar uncertainty avoidance score to the United States and the United Kingdom with all three countries being relatively comfortable with uncertainty [33]. In healthcare, certainty is an illusion [34] and an ability to tolerate uncertainty is vital to modern healthcare systems. China’s ability to tolerate uncertainty may facilitate the adoption of shared decision making. Additionally, survey data suggests that there may be willingness amongst Chinese patients to get involved in their medical care and to be better informed about their medical problems. However, the lack of time in consultations and a mismatch between doctor and patient perceptions have been identified as major barriers for effective communication and decision making [35–37].
Barriers to Shared Decision Making in China In addition to the general cultural considerations outlined above, there are specific aspects of the medical system in China that may impede adoption of shared decision making. Firstly, there is a lack of appreciation for medical humanities in Chinese medical society. This results in limited recognition of the importance of patient-centered care and the principals of medical ethics amongst medical students and staff. Therefore the values that underpin the foundations of shared decision making are deficient. It has also been argued that the fee-for-service model in China makes it difficult for patients to receive unbiased information and therefore shared decision making is impeded [38]. In order to embed shared decision making into a healthcare system, it is important that clinicians have appropriate tools available to them [39]. In China, these tools and systems are lacking. The situation with cancer screening provides an illustrative case study. The ‘‘Cancer Prevention and Treatment three-year Action Plan’’ [40] recommends population screening for lung, liver, gastric, esophageal, colorectal, breast and cervical cancer and screening rates are increasing [41]. National cancer screening guidelines encourage shared decision making, thus demonstrating a willingness to incorporate this process into clinical practice at a policy
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level [42]. However, this sentiment has not been backed up with practical support as guidelines do not include a specific implementation plan or provide any tools to aid shared decision making. As a result, we believe that few doctors in China practice shared decision making with patients or discuss the pros, cons, and uncertainties of screening. This may be because many health professionals involved in cancer screening do not have clear ideas of potential benefits and harms. Similarly, substantial proportion of the population in China have an ‘‘annual physical’’ in various healthcare organizations, but little information about the effects of these annual checkups are provided to them and there is no evidence to suggest that shared decision making is integral to the process. The future of Shared Decision Making in China The successful implementation of shared decision making in China could present a substantial challenge. Although there are an abundance of tools to aid shared decision making internationally, to adapt these for China and evaluate their uses will require time and resources, as well as commitments from relevant organisations. There would also be a need for research on the acceptability, long-term effectiveness and costs of patient decision aids in China. Implementation of decision aids would have to be done in conjunction with a concerted effort to train existing and new clinicians in the skills required to engage patients in meaningful discourse. Furthermore, healthcare services will need to be designed to facilitate and promote shared decision making in a variety of settings. There is much to be done, and a long journey to travel, before shared decision making becomes accepted as the normal way of making health decisions in China. Conflict of Interest None declared. References [1] Blumenthal D, Hsiao W. Lessons from the East—China’s rapidly evolving health care system. New England Journal of Medicine 2015;372(14):1281–5. [2] Wang C, Rao K, Wu S, Liu Q. Health care in China: improvement, challenges, and reform. CHEST Journal 2013;143(2):524–31. [3] Yip WC-M, Hsiao WC, Chen W, Hu S, Ma J, Maynard A. Early appraisal of China’s huge and complex health-care reforms. The Lancet 2012;379(9818):833–42. [4] Information Office of the State Council. A White Paper on Medical and Health Services in China: Information Office of the State Council The People’s Republic of China,; 2012 [03.04.2017]. Available from: http://english.gov.cn/ archive/white paper/2014/08/23/content 281474982986476.htm. [5] Meng Q, Xu L, Zhang Y, Qian J, Cai M, Xin Y, et al. Trends in access to health services and financial protection in China between 2003 and 2011: a crosssectional study. The Lancet 2012;379(9818):805–14. [6] Wu D, Wang Y, Lam KF, Hesketh T. Health system reforms, violence against doctors and job satisfaction in the medical profession: a cross-sectional survey in Zhejiang Province, Eastern China. BMJ open 2014;4(12):e006431. [7] Lien SS, Kosik RO, Fan AP, Huang L, Zhao X, Chang X, et al. 10-year trends in the production and attrition of Chinese medical graduates: an analysis of nationwide data. The Lancet 2016;388:S11. [8] PRC NHaFPCot. China sets up new system to optimize medical resources 2015 [03.04.2017]. Available from: http://en.nhfpc.gov.cn/201509/16/c 46816.htm. [9] Zhang X, Sleeboom-Faulkner M. Tensions between medical professionals and patients in mainland China. Cambridge Quarterly of Healthcare Ethics 2011;20(03):458–65. [10] Jia X, Zhou H, Zhao Y, Zheng L, Wei Q, Zheng X. Investigation on hospital violence 2003-2012 in China. Chinese Hospitals 2014;(18):1–3. [11] Shan L, Li Y, Ding D, Wu Q, Liu C, Jiao M, et al. Patient Satisfaction with Hospital Inpatient Care: Effects of Trust, Medical Insurance and Perceived Quality of Care. PloS one 2016;11(10):e0164366. [12] Tucker JD, Cheng Y, Wong B, Gong N, Nie J-B, Zhu W, et al. Patient–physician mistrust and violence against physicians in Guangdong Province, China: a qualitative study. BMJ open 2015;5(10):e008221. [13] Zhao D-H, Rao K-Q, Zhang Z-R. Patient trust in physicians: empirical evidence from Shanghai. China. Chinese medical journal 2016;129(7):814.
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Please cite this article in press as: Yao M, et al. Call for Shared Decision Making in China: Challenges and Opportunities. Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) (2017), http://dx.doi.org/10.1016/j.zefq.2017.05.004