27 March 2018

How Can Medical Institutions Adjust to the Multiple-site Practice of Physicians

This article was by Luo Ai(Partner), Xie Minru(Associate) and Guo Xian(Legal Assistant).

Changes in policies of the multiple-site practice of physicians

Encouraging physicians to practice in multiple places is a policy that has been raised much earlier. On March 17th, 2009, Opinions of the CPC Central Committee and the State Council on Deepening the Reform of the Medical and Health Care System (“Opinions”) has proposed that “We shall steadily facilitate the reasonable movement of medical personnel, facilitate vertical and horizontal exchanges of talents among different medical institutions, and study and explore the multiple-site practice of registered physicians”. On September 11th, 2009, based on the requirement of the aforementioned Opinions, the former Ministry of Health issued the Notice on Issues Concerning Multiple-site Practice of Physicians (“Notice of 2009”), which defined “multiple-site practice of physicians” as physicians’ practice in more than one medical institution, excluding their going out for consultation, and put forward related opinions on classification management, requirements for pilot projects and application procedures. Afterwards, Guangdong, Sichuan, Beijing and Hainan became the pilot districts of the first round.

On July 12th, 2011, the former Ministry of Health issued the Notice on Expanding Pilot Area of the Multiple-site Practice of Physicians (“Notice of 2011”), deciding to expand the pilot area to all state-level pilot cities of public hospital reform (199 cities in total in 4 batches), province-level pilot cities of public hospital reform and two more prefecture-level cities chosen by each province (autonomous region and municipality directly under the Central Government).

On November 5th, 2014, the National Health and Family Planning Commission and four other  ministries issued Several Opinions on Promoting and Standardizing the Multiple-site Practice of Physicians (“Opinions of 2014”), which further clarified “multiple-site practice of physicians” as physicians’ practice in two or more medical institutions at regular intervals during their period of registration, and further standardized and clarified the qualifications for physicians to practice in multiple places, management of registration, personnel management, medical liability, etc. 

On April 1st, 2017, Administrative Measures for the Registration of Practicing Medical Doctors took effect and it stipulates that physicians can choose sites in a different province as their additional practice sites, which further expand the scope of additional sites where physicians can practice. As a result, physicians now can apply to practice nationwide.

Can the hospitals decide whether their physicians can practice in additional sites

It is all too obvious that multiple-site practice of physicians will considerably affect the personnel management of their primary practice institutions. For example, if a physician practices in additional sites, his/her working time and efforts in the primary practice institution will decrease, which affects the quality of medical services and scientific research tasks; if the physician in charge of a significant scientific research project applies for multiple-site practice, to the primary institution may face higher risk of leakage of confidential information; and if a physician practices in multiple sites, the patients whom he/she used to serve in the primary practice institution may be diverted to additional practice sites. Therefore, whether the primary practice institution can turn down their physicians’ application for practicing in multiple sites? 

On this issue, we note that both the Notice of 2009 and Notice 2011 stipulate that the approval of the primary practice institutions is one of the application requirements. From the two aforementioned Notices, it can be seen that the primary practice institutions have full power to decide whether their physicians can practice in another hospital or not. However, this situation changed after the issuance and implementation of Opinions of 2014, which stipulates in its Article 3 (2) that physicians who plan for multiple-site practice should obtain the approval of the primary practice medical institution, but some qualified places can explore and build up the system where physicians can practice in multiple sites after they report to their primary practice institutions. From then on, several pilot provinces and cities[1] began to reduce the restriction on application for multiple-site practice and the discretion of primary practice institutions were weakened.

Meanwhile, we also notice that although in some pilot provinces and cities, the requirement for application changed from acquiring approval from the primary practice institutions to merely reporting to them, the reporting procedure is not an empty shell. In March 2017, Mr. Hu, a chief physician at the psychiatry department of Tianyou Hospital Affiliated to Wuhan University of Technology was discharged because he used the brand and influence of Tianyou to do part-time practice in Wuzhong Psychiatric Hospital in Wuhan and was regularly in clinic without any notification and authorization. Wang Xiaonan, the head of Tianyou Hospital explained that they had never opposed to the multiple-site practice of physicians, but forbade their physicians to take on part-time jobs without prior notification to the hospital. From the result of this incident, we can conclude that in some pilot provinces and cities, there is no need for a physician to acquire the approval of his/her primary practice institution, but it does not mean that the primary practice institution has lost it control on this issue, or else the multiple-site practice of physicians will become an unorderly flow of physicians.  

In conclusion, generally physicians should be approved by their primary practice institutions before their multiple-site practice, and then the primary practice institution can decide whether to approve or disapprove according to its operational needs. On the other hand, in some pilot provinces and cities, physicians only need to fulfill the reporting procedure and then they can practice in additional sites; the objection of the primary practice institution pales into insignificance, but the reporting procedure is still vital and necessary, so hospitals can still carry out effective management on the practice of physicians.   

Can hospitals set limits on physicians’  practice in multiple sites

Article 3(4) of the Opinions of 2014 explicitly stipulates that medical institutions as primary practice sites should support the multiple-site practice of physicians and improve internal management. After the medical institution approves of a physician’s multiple-site, it should therefore modify the responsibilities of physician reasonably, and formulate reasonable stipulations on evaluation, award, discipline, competition for a post, etc. The multiple-site practice of physicians should not impede their promotion opportunity and academic status. Then, can hospitals set up some suitable limits on who may practice at multiple-sites and how long they may do it, to ensure the high quality and safety of medical treatment?

On this issue, according to the Policies and Regulations Room of Central Commission for Discipline Inspection’s answers to several questions on Interim Provisions on Disciplinary Actions against Personnel of Public Institutions (“whether the personnel of public institutions can do part-time job in enterprises, depends on the related regulations of their localities, industries, systems, employers, etc. to restrict part-time job in enterprises.”) and the Article 39(4) of Labor Contract Law (“where an employee simultaneously enters an employment relationship with other employers and thus seriously affects his/her completion of the tasks of the employer, or the employee refuses to make the ratification after the employer points out the problem, the employer may dissolve the labor contract”), we hold the opinion that if hospitals will not completely stop their physicians from practicing in multiple places which may constitute violation of regulations on multiple-site practice of physicians, they should have the privilege to formulate their internal rules and regulations or enter into agreements with physicians on their part-time jobs, to ensure effective management and operation of hospitals and high quality and safety of medical treatment. For example:

  • On who can practice in multiple site, Opinion in 2004 only stipulates “a physician in multiple-site practice should at least hold the intermediate certificate of profession and title, and has practiced in a profession field for more than five years; be of good health to bear the workload of multiple-site practice; and have passed the latest two consecutive regular assessments of physicians”. Based on this, without any violation of laws and regulations, hospitals can study on and formulate some supplemental rules and regulations, such as “the principals of administrative departments and community medical institutions should be forbidden to practice in multiple places”, in order to ensure the stability of senior management of hospitals and help to avoid leakage of hospitals’ secrets.
  • On the duration of time for multiple-site practice, hospitals can also study on and formulate some related rules and regulations, such as “physicians may arrange one day per week for multiple-site practice”, to ensure the physicians’ working hours and working quality when they stay at the primary medical institutions.  

In conclusion, beginning from the year of 2009, along with the piecemeal development of pilot projects and related regulations, multiple-site practice of physicians is an irresistible trend. Under this circumstance, primary practice hospitals are bound to be influenced more or less by this trend. Although hospitals cannot thoroughly stop all their physicians from practicing in multiple places, they can adopt comprehensive methods including consent, reporting procedure and formulating related rules and regulations, to avoid out-of-order movement of physicians and ensure effective management and operation of hospitals as well as high quality and safety of medical treatment.

[1]According to related information at official websites of all the provincial health commissions, we found that twelve provinces and cities including Fujian, Shanxi, Guangdong, Guangxi, Hainan, Heilongjiang, Hunan, Liaoning, Shandong, Sichuan, Guizhou, Wuhan of Hubei have announced that physicians can practice in multiple places after completing the procedure of reporting to the primary practice institutions.

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