Practicing clinical medicine in a post-socialist state : an empirical study on professional autonomy of Chinese urban doctors

Abstract

The relationship between the state and its professions has long been overlooked in the sociology of professions. Based on empirical data collected by in-depth interviews and through participant observation in Beijing, this thesis analyzed the dynamic relationship between Chinese urban medical professionals and the post-socialist state of the People’s Republic of China.

The study reveals that the post-socialist state continues to wield large influence in the social, economic and technical areas of this profession and retain tight controls despite being in an era of market transition. This control is principally realized through the current healthcare system. Public hospitals have monopolized healthcare delivery, which gives medical professionals little alternative but to become state employees. Practicing in public healthcare organizations and lacking “exit” opportunities, they are left with little to negotiate their working conditions with the state and thus have little corporate autonomy.

The lack of corporate autonomy immediately leads to the erosion of their clinical autonomy. Because of the pressure of self-financing imposed by the state, clinical practitioners consequently induce patients to accept unnecessary and excessive medical care. When they make decisions in practice, revenue generation is often recognized as more important than serving patients. This is a major source of clinical autonomy erosion. In prioritizing profit-making, Chinese urban medical professionals are perceived by the public as an “unethical profession.”The mutual distrust and conflict between professionals and patients have increased significantly in recent years. To protect themselves from growing medical disputes and, sometimes, even violence, Chinese doctors have developed “defensive medicine” strategies in their practices and in their interaction with patients. This is yet another source of clinical autonomy erosion as self-protection becomes an important calculation in balance with their own medical competence and patients’ interests.

The case of medical professionals in urban China challenges Freidson’s endogenous view of professional autonomy and his distinction between corporate and technical autonomy. It also questions the simple construction of conflicting relationships between the state and professionals. Rather, this dissertation finds that there is an exchange-like relationship between professionals and the state. Professionals are not simply losers in their interaction with the state, they do profit as well as they retain job security in market transition, earn considerable economic benefits through their practice, and are shielded by public hospitals in medical disputes even if they are punished by those hospitals. Doctors receive all these gains at the large cost however as they rarely enjoy professional autonomy, suffer from a negative public image, and become scapegoats for the problematic healthcare system and the state.

At the end of this thesis, I provide suggestions for the ongoing reform of China’s healthcare system. These suggestions include liberating doctors through the development of private practice and strengthening supervision over doctors’ behavior while increasing financial support for public hospitals.