February 18, 2014: a man bursts into a doctor’s office in a large hospital in Yixian, in the Hebei province of Northern China. Instead of collapsing onto the examination table complaining of aches and pains, he pulls out a knife and threatens to avenge his brother who had been treated in that hospital, but had never fully recovered. Whether or not this particular physician on the hospital’s staff actually examined or operated on the brother is irrelevant. The man stabs the doctor to death and leaves him to be discovered by the hospital staff the next morning. Since the implementation of a reformed national health care plan in 2003, these kinds of attacks are becoming all too common. Many Chinese must cope with the shortcomings of the new health care system, and for frustrated patients the doctors, nurses, and hospitals are the scapegoats.

Over a decade ago, the Chinese government implemented the New Rural Cooperative Medical Care System (NRCMCS) to extend affordable health care to rural populations. In theory this plan would give people in isolated areas access to cheap, professional medical care. In practice, it has spread Chinese doctors too thin, draining health care resources across the country, and making it difficult to find reliable, high-quality treatment. The hierarchy of funding distribution in the NRCMCS plan makes basic, local care affordable but does nothing to mitigate the high costs of more complicated treatment at central city hospitals. The consequences of this are twofold: the people in need of complex procedures still only have a slim chance of receiving treatment at a price that they can pay, and doctors must shoulder the burden of more patients while they are expected to perform the same quality procedures in the same limited amount of time on the same slim salary. Ultimately this has led to overworked doctors, sloppier procedures, and angry patients.

Unfortunately, the number of patient attacks on doctors is only increasing. According to survey results from the China Hospital Management Association, disputes about medical treatment have risen 23 percent every year since 2002. In some cases the patient will personally attack the doctor who treated them; in others, family or close friends of the patient will retaliate. Frustrated patients are looking for someone to blame, and doctors are the easiest to point fingers at. Ultimately, the Chinese government is responsible for the systematic failures of national health care, but patients are so removed from the medical system that they have no effective way to voice their grievances, receive compensation for legitimate malpractice, or siphon frustration at the cost of medical care. Thus, in many cases the doctor is not just the scapegoat for the government’s mistakes, but an enemy with bad intentions who deserves to be punished. In the eyes of some patients, this entirely justifies physical retaliation.

But perhaps the most troubling consequence of the current medical care system is the prevailing attitude that backroom deals are the only way to receive adequate care and payment. The NCRMCS does nothing to subsidize the costs of complex procedures, and patients must pay exorbitant fees for access to these operations. At the same time, doctors are underpaid and over-worked, and many patients realize that they have little incentive to operate as well as they can. Doctors just need to fill their ever-expanding quotas, and if getting the job done on time requires cutting corners during a routine tumor removal, then the surgeon has every reason to underperform. Thus, families may slip a little red envelope of cash under the operating room door to provide some extra incentive. This perpetuates the corruption on the doctors’ end, contributing to the already shaky reputation of what it takes to get an operation done well. It also puts more pressure on doctors and gives patients more reason to retaliate if the procedure doesn’t go as planned. Doctors have no room to breathe, stuck between unrealistic quotas, demanding and frustrated patients, and expectations of perfection. Patients are suspicious of doctors’ motivations, fearful of malpractice, and overpaying for treatment. For families of those that failed to survive complex procedures, the doctor now has the patient’s blood on their hands. In the Chinese medical system, where lawsuits (much less successful ones) are few and far between, direct violence is the easiest option.

Looking to the future, what will happen to Chinese healthcare? Will the violence continue to escalate? Will some backroom system develop to siphon all the frustration and bribery away from violent attacks? Will there even be enough doctors in the years to come to support China’s ambitious health care spending budget of 1 trillion dollars by the year 2020? In addition to the current battle between doctors and patients, there are two forces at odds with one another within the Chinese health care system. First, the potentially dangerous, tiring, underpaid, and overworked lifestyle of a doctor in China is less than appealing. This is causing young medical students to change professions and current practitioners to dissuade their children from going into medicine. In the coming years, the current shortage of doctors may get worse, even as more doctors are needed to treat millions of new patients. Second, multinational pharmaceutical companies are investing heavily in Chinese health care. This is further increasing the expansion of health care, pushing the limits of how many people the system can treat. When put together, the shortage of doctors and pressure to expand health care spread China’s doctors even more thinly.

Taking into account both sides of the Chinese medical system, it is apparent that something has gone wrong. Patients are angry. Doctors are too tired to perform well. The two groups have no way of communicating. Violence is spreading and sucking the trust out of the doctor-patient relationship. It is apparent that the Chinese health care system is in need of a serious change. The lack of an effective legal outlet for legitimate malpractice, the communication gap between doctors and patients, the poor distribution of limited government funds for medical resources, and the unreasonable quantity of patients doctors are expected to provide care for all contribute to the system’s failure. A barrier has risen between doctor and patient, and seems to take the “care” out of health care, turning medicine in China into a begrudging and dangerous occupation.