Introduction
Medical disputes usually refer to disputes between doctors and patients who have inconsistent understanding of the consequences of medical treatments and their causes, which maybe then brought to the health administrative department or judicial authority for accountability or compensation for losses. Medical disputes include civil disputes (civil compensation), administrative disputes (administrative punishment) and criminal liability (crime of medical malpractice) between doctors and patients in the broad sense. Based on whether there is a fault in the process of diagnosis and treatment, medical disputes can be divided into medical disputes with or without faults. Medical disputes with faults refer to those caused by medical malpractice and errors, and medical disputes without faults are caused by medical accidents and complications. Medical disputes also can be divided into iatrogenic disputes and non-iatrogenic disputes based on whether they are caused by iatrogenic reasons or not. The medical complaints are a common phenomenon in China. There are many medical complaints in the hospital every day and they are resolved through negotiations between doctors and patients or the administrative department in the hospital. When a complaint can not be resolved by negotiations between doctors and patients or the administrative department in the hospital, it will turn into a medical dispute. The medical dispute is a very sharp contradiction. There is a conceptual difference with a complaint that medical disputes are the products of contradictions intensified to a certain stage, and they will be brought to the health administrative department of region or judicial authority for accountability or compensation for losses. The doctor-patient relationship is at the core of interpersonal interaction in the medical setting, and is thus crucial for ensuring healthcare delivery. Specifically, the doctor-patient relationship consists of direct interactions between the care provider and care user [
1]. However, the two parties have different understandings of the disputed facts, dispute with each other and express their opinions. The settlement of medical disputes is generally handled through consultation between doctors and patients. If the consultation fails, the parties may apply for mediation to the health administration department or directly file a civil lawsuit to the people’s court [
2].
The doctor-patient relationship is generally harmonious in developed countries such as, where there are relatively comprehensive laws and medical insurance systems. However, the United Kingdom and United States experience high rates of dispute across medical institutions [
3]. In 2005, Michigan Medicine conducted a workplace violence survey among emergency physicians, finding that 74.9% suffered verbal threats at least once per year, with 28.1% suffering physical violence within the year [
4]. In developing countries, a survey showed that more than half of sampled medical staff had experienced medical disputes at least once [
5]. In sum, the literature shows that doctor-patient disputes now constitute a global issue [
6].
In China, the number of medical disputes has surged since the beginning of the twenty-first century [
7]. Nationally, medical disputes have increased by an annual rate of 22.9% since China implemented the Medical Malpractice Management Regulation in September 2002 [
8]; in some regions, this increase has reached 40% [
9]. According to data released by the National Health Commission of China, there were 73 million outpatients in medical institutions across the nation as of 2015, with approximately 70,000 of these cases ultimately ending in medical disputes. In 2017, there were 12,734 medical disputes, followed by a slight decrease to 12,249 in 2018 and subsequent increase to 18,112 in 2019 [
10]. As an international financial center, the city of Shanghai contains some of the richest medical resources in China, but the number of medical disputes is rising at an annual rate of 11% [
11]. The collective dedication of health workers during COVID-19 has once again provided us a greater understanding of medical profession. At present, although the doctor-patient relationship in China is improving as a whole, there are still some disharmonious phenomena [
12]. Domestic scholars tend to focus on the doctor-patient relationship in six main areas: medical science, hospital management research, health care ethics, public relations research, legal system and conflict resolution mechanism. On the other hand, foreign scholars tend to concentrate on the modes of doctor-patient relationships [
13].
At present, the main influencing factors of medical disputes in China can be summarized as doctor’s factors, patient’s factors, social’s factors and so on. Among them, doctor’s factors mainly include diagnosis and treatment quality, insufficient communication, service attitude, awareness of responsibility, medical supplies and equipment, medical ethics and so on. The patient’s factors include misunderstanding of medical behavior, unreasonable appeal, high expectation of prognosis, refuse to cooperate with treatment, mistrust and so on. Social causes mainly include related laws and regulations are not matched, media reports on medical disputes are not objective and fair, the total amount of medical resources is insufficient, the regional distribution is uneven, the mechanism of medical dispute settlement is not perfect and so on [
14].
The scholars in the developed countries such as Britain and Amercia researched medical disputes earlier, they researched the doctor-patient relations firstly [
15]. Beckman HB once pointed out that 70% of medical disputes came from insufficient communication, the sufficient communication between doctor and patient is a strong guarantee to prevent medical disputes, and the insufficient communication is the main factor affecting medical disputes [
16]. Japan is a country with a relatively low incidence of medical disputes in the world. The Japanese scholars thought that hospital management, respect for informed consent of patients, the establishment of an effective medical liability insurance system, and the establishment of the perfect system of medical dispute settlement were important reasons that affected medical disputes [
17]. Some scholars also put forward that cultural background, educational background and other humanistic factors were important factors that led to medical disputes. The mainstream scholars thought the sufficient communication between doctor and patient can help make up for the two sides of the differences in understanding, and then prevented the formation of medical disputes [
14].
Now, there are many researches on doctor-patient relationship, most of which are qualitative researches. The quantitative researches are few from the perspective of hospital management with COVID-19.This study aimed to explore the causes and factors behind medical disputes that occurred across eight hospitals in Shanghai over a three-year period (January 2018 to December 2020), analyze the risk factors, thus providing targeted suggestions for amelioration. We believe that our findings will both provide a resource that hospitals in Shanghai can use to prevent medical disputes and serve as a foundation for the further research on doctor-patient relationship.
Methods
This study innovatively took hospital management as the cut-in point; based on the perspectives of doctors and patients as well as disease-related factors, we analyzed information from 561 medical disputes that occurred in Shanghai over a three-year period (January 2018 to December 2020), as extracted via multistage sampling. Specifically, we analyzed the high-risk factors for disputes and conducted a correlation test to determine which influencing factors were likely to further escalate disputes.
Study sample
We initially employed multistage sampling to collect information on 561 medical disputes that occurred in two Class A tertiary hospitals, two Class A secondary hospitals, and four community hospitals in Shanghai over a three-year period (2018 to 2020). The Class A tertiary hospital aims to diagnosis and treat the difficult and critical diseases. The Class A secondary hospital aims to diagnosis and treat the common diseases. The community hospital aims to treat and manage the chronic diseases. Of these, 41 cases were removed due to incomplete information, resulting in 520 cases with complete information for analysis (pass rate of 92.69%).
Research measures
As previously developed by the current research team, this study used the Questionnaire on Medical Dispute Case Analysis [
13], which is comprised of six dimensions covering 23 items, including demographic indicators (six items), medical factors (four items), patient factors (two items), disease factors (four items), communication factors (two items), and dispute handling factors (five items).
The demographic indicators include gender, age, native place, occupation, education, marriage. The medical factors include attending doctor, medical quality, expert opinion, non-technical factor. The expert opinions of medical factors include violation of diagnosis and treatment regulation, belated diagnosis and treatment, imperfect operation, low technical level and so on. The patient factors include medical insurance and non-error medical disputes factors. The non-error medical disputes factors of patient factors include misunderstanding of medical behavior, bad attitude, mistrust, inadequate medical knowledge and so on. The communication factors include doctor’s factors and patient’s factors. The doctor’s factors of communication factors include critical behavior to patients, insufficient communication and others. The patient’s factors of communication factors include bad attitude, patient’s speech threatened the door and so on. The dispute handling factors include dispute level, amount of compensation, handling time, violent conflict and so on. The dispute level include Level1, Level2, Level3, Level4.The amount of compensation include above one million REN MIN BI, between 500,000 and one million REN MIN BI, between 100,000 and 500,000 REN MIN BI, below 100,000 REN MIN BI. This classification method comes from the research that was conducted by Yonghai Bai about influencing factors of medical disputes in Class A tertiary hospital in Shanghai [
13].
Procedures
We conducted a retrospective analysis and processed documents related to the obtained cases. Prior to the investigation, we requested that the hospital president in charge of medical disputes help communicate with the director of reception office and we trained the investigators. The researcher introduced the plan, the purpose, the method of the research, the situation related to the questionnaire to all the investigators, so that the investigators can have an overall understanding of the project, and we explains the steps, requirements, time arrangement, workload and other specific issues of the questionnaire. We trained the investigators to make them clear about all the contents of the questionnaire, the way of filling and the items need to be concerned of the questionnaire. According to the requirements and steps of the formal investigation, we conduct a simulation investigation and let each investigator practice from beginning to end. Then, we summarized the problems in the simulation investigation and solved these problems through discussion or explanation. The discussion or explanation include that organizational management measures, guidance and supervision measures, review and inspection measures, summary and exchange system.
Then we went to the hospital medical office of the hospital and the director of the dispute office helped find the case files of medical disputes from January 2018 to December 2020. The investigators first read and analyzed the medical dispute cases, and then according to the questions in the questionnaire, he extracted information about doctors, patients and diseases from the medical cases. At the same time, he filled in the questionnaire timely. In the questionnaire, there is an option for the amount of compensation for medical disputes. In the medical disputes files, there is the amount of compensation for disputes. We extracted the amount of compensation information from the case of medical disputes and filled in the questionnaire. Once one questionnaire was filled out, another investigator performed strict double-check task. During this process, all questions that we asked were answered timely by the director of the dispute office. After the investigation in one hospital, we carried out the same investigation in another hospital, and a total of eight hospitals were investigated.
Data analysis
The data collected thereby collected were recorded via Microsoft Excel and processed using IBM SPSS18. Diseases were divided into four categories in line with the principle of case classification [
18]; this included simple general cases, simple emergent cases, complex intractable cases, and complex critical cases. Medical disputes were classified into one of four levels, including level 4 (compensation below 100,000 REN MIN BI), level 3 (compensation between 100,000 and 500,000 REN MIN BI), level 2 (compensation between 500,000 and one million REN MIN BI), and level 1 (compensation above one million REN MIN BI) [
19]. Taking the disease-related, doctor-related, and patient-related factors as independent variables and the dispute levels as dependent variables, we conducted a one-way ANOVA to more thoroughly analyze the medical dispute levels. The results were then substituted into a multiple logistic regression model to obtain the indicators of high-risk factors for medical disputes (significance at 0.05).
Conclusion
This study’s investigation of 520 medical disputes in Shanghai revealed that issues were variously influenced by doctors, patients, and disease. For doctors, the main factors included professional title, violations of diagnosis and treatment regulations, misdiagnosis and mistreatment, belated diagnosis and treatment, imperfect operations, insufficient condition evaluations, low technical levels, the lack of experience, and defective case records, among others. For patients, prominent factors included the misunderstanding of medical behavior and high expectations for prognosis. Finally, factors related to disease included the disease classification and treatment effects. Among all factors, the disease classification, treatment effects, doctor’s violation of diagnosis and treatment regulations, and doctor’s low technical levels were the main reasons for different dispute levels, and are thus high-risk factors that require close attention. In addition to strengthening clinical and communication skills training, hospitals should establish quality control mechanisms for case records and construct rapid, standardized referral mechanisms. In the interpersonal context, patients should actively cooperate with their doctors in the treatment process, moderate any unrealistic expectations that patients may have about the outcomes. Doctors should also attach great importance to the quality and urgency of treatment given to critically ill patients, who must be informed about their prognoses in a timely manner to avoid medical disputes and physical deterioration. During the COVID-19 pandemic particularly, doctors and patients should strengthen empathy and trust more, then defeat disease together.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.