?

Perspectives on China′s General Medicine Education,Training,Development and Challenges

FANG Yu-ting

Affiliation：United Family Healthcare

【Key words】General medicine；Education，medical；Development；Challenges

The Chinese government has made efforts to improve primary health care to its citizens.This effort includes the training of general practtioners(GP) that are able to meet China′s health care needs.

I am honored to have been invited by this journal as a family doctor in United Family Healthcare (UFH) to discuss the challenges facing China′s GP training and development.To start,here is some background on myself and experience in medical education in China.I am a Chinese-American trained and dual boarded in Family Medicine and Internal Medicine in the United States (US).From 2002—2005,I have been a core faculty member of US residency programs and participated in the training,evaluation and curriculum development for internal medicine and family medicine residents.I have also help with the clinical training of US medical students,physician assistants and nurse practitioners.I worked in UFH as a family doctor from 2005—2009 and 2012 until now.UFH is a healthcare network that started in 1995 in Beijing and now includes hospitals and clinics in Beijing,Tianjin,Shanghai,Qingdao,Guangzhou,Wuxi,and Ulaanbaatar (Mongolia).

Since its inception,UFH has employed a wide specialty of physicians from China and abroad.One specialty that sees a significant portion of patients in UFH is family medicine,a type of general medicine.UFH family physicians almost all had their family medicine training outside of China,from countries with established histories of family or general medicine training such as the UK,US,Canada and Australia.In 2012,UFH started its own internal family medicine training program with me as the chair of the program.Since the first class of recruits in 2013,14 Chinese doctors have come through UFH′s training program.In the writing of this article,I draw mostly upon my experience with these trainees and discussions with general practitioner training programs in Chinese hospitals about their experiences.

As a family doctor and internist,I tend to approach problems in this manner：

●Get a history.How a problem got to where it is could usually point to how to resolve the problem.

●Creating a problems list.This generally provides an exhaustive list of not only the "chief compliant" but also of other issues as they may be interconnected now or in the future.Eg.High blood pressure in a patient with a common cold may limit the medication choices for that patient.

●Focus on a few do-able items to develop a plan and re-evaluate to see if things are working.

1The chief compliant:How to train well qualified general practitioners?

News of Chinese citizens finding it hard to see the doctors they want and afford health care costs are staples in Chinese media.The estimate total physicians per 1 000 people in China in 2012 is 1.9.In comparison,the UK has 2.5,US has 2.8,Singapore has 2.0(2013),and South Korea has 2.1/1 000 persons.As the ratio of doctors to persons is not too much out of proportion compared to many other countries,it has been thought that the overspecialization of physicians and insufficient number of general practitioners may be reasons why patients find it difficult to get their medical needs addressed in China.In reaction,China identified the training of qualified GPs to be integral to the success of health reform.The government has also taken steps to make primary care more attractive to doctors.Based on publically available coverage of government policies,the Chinese central government′s areas of focus in GP training has included the following:

●Consolidating public health care centers to create a standardized system of community health centers (CHC) and clinics.

●Improving the pay of GPs and CHC infrastructure to make GP career attractive to physicians.

●Increase patients interest in seeing GPs by providing reimbursement incentives for patients to such as lower out of pocket costs for medications and easier access to specialists.

●Increasing the number of GP faculty by training specialists in primary care principles.

●Increasing the number and quality of GP residencies.

●Incorporating primary care education into medical school curriculum through didactics and rotations in community health clinics.

So what are the challenges to the training of more general practitioners?

2The focused problems list

Challenges that currently face the training of qualified general practitioners include：

2.1The best medical students are not entering GP residency programs.Programs to provide scholarships to GP residents from rural areas may help with retention,but it is also important to attract China′s best medical students to compete for the best GP residencies.

2.2GP residency programs are graduating residents who are not all ready to start practicing the scope of GP doctors.Contributing factors may include：

●The lack of GP faculty who practice general medicine.GP faculty in countries with strong GP training programs act as the GP trainees′ advocates,mentors,and evaluators.The lack of such faculty in China means that current GP trainees do not have GP mentorship.Despite this,programs such Peking University′s Affiliated Hospitals′ GP Training Centers have shown that dedicated specialty faculty with strong teaching foundation and dedication to GP principles could be a good interim solution.

●Residencies have limited authorization to evaluate resident performance critically.

●Patient exposure during rotations not broad enough.In most academic hospitals,it is difficult to find general wards of any specialty.In addition,specialties are often further subdivided.While a GP resident in the UK may see a patient with congestive heart failure,myocardial infarction,atrial fibrillation in a cardiology rotation,a GP resident in China may only see electrophysiology patients when rotating in cardiology.

●Limited continuity clinic experience during GP residency training.Residency programs like the one in Sir Run Run Shaw hospital in Hangzhou show that continuity clinics during all three years of residency is possible in China.

2.3Practices that unintentionally distracts from the development of GP residents and community health doctors.

●Limiting academic hospitals from forming GP departments perpetuates the misconception that "GPs only see minor diseases" and that GP medicine is not an academic medical specialty.

●Overextension of the role of the GP before the current GPs are ready.Eg.Health departments expecting GPs to provide public health management.Although public health skills are important,standardized rating methods for GPs internationally shows that incorporating public health concerns in clinical practice is an advance skill with which not all GPs may be proficient.During the development phase of China′s GP program,it may be more efficient to concentrate on GPs being able to manage the most common reasons for health visits such as provide care to sick children and basic prenatal care.Once GPs are able to provide a wide scope of care,it will be easier for them to understand how to provide community and public healthcare.

●Health facility regulations originally designed for hospitals being applied to clinics and ancillary facilities.

?Medication and testing limits hinders community health centers from meeting the primary health needs of their community.

?Standards that are difficult to set up and maintain such as infection control measures designed for hospitals.Most CHC′s do not see fever patients because their local regulations only allow patients with fever to be seen in specialized facilities.As insightful Shanghai CHC director once said to me and a group of visiting doctors,"There′s no reason to not let CHC see patients with fever.SARS doesn′t happen every day".When GPs are not allowed to see how "normal" fever patient patterns present,they are much less likely to be helpful when they are needed to help detect abnormal patterns of disease early on and be full partners in public health endeavors.

?Requirements that are not proven to improve health care outcomes such as requiring private clinics to hire senior GPs or GPs with a public health certifications.

●Blocked oversea educational site resources.Information from places like Taiwan and Hong Kong with more developed primary care infrastructure could be helpful to the development of GP in China.This is especially true for information rich government based information such as the US national library of medicine website Pubmed or Center for Disease Control.

●Compartmentalized health care services.Many cities send all patient with Tuberculosis,Hepatitis B and Suicidal patients to specialty hospitals.This prevents GP residents from knowing these "common illnesses".Lacking practical experience with common diseases,it is difficult for GPs to be effective public health partners.Another example are vaccine stations.Because vaccine stations are effective in providing population based vaccinations,even pediatricians in large academic hospitals may be unfamiliar with the latest vaccine regimes.Internists have even less experience with vaccinations and often do not recommend needed vaccinations.Also,because vaccine stations operate outside of mainstream academic institutions,and only provide vaccines to healthy children,a vaccine gap occurs for high risk kids like premature babies and children with chronic diseases.Because of the above realities,local health departments may consider giving permission for a few academic hospitals with GP residencies to have their own GP clinics and GP wards to treat a wider variety of patients so GP residents may learn how to manage common diseases more effectively.

3Possible solutions for the problems list

The goal as with most complex problems in medicine,is to break down the complex problem into separate smaller,more manageable pieces.

3.1The best medical students are not entering GP residency programs.Possible solutions：

●Provide financial assistance to those entering good medical schools if they become GP residents.

●Establish GP departments in top Chinese medical schools to raise the status of General Medicine.

3.2GP residency programs are graduating residents who are not all ready to start practicing the scope of GP doctors and regulations that unintentionally deter primary care development may be addressed jointly by：

●Encouraging academic hospitals to forming primary care/GP departments with dedicated faculty.

●Mandate CHC manage 90% of all complaints in their community,including kids with acute and chronic illnesses.

●Consider suspending health facility regulations originally designed for hospitals being applied to some CHCs and private clinics for 3 years while the impact of the regulations are re-examined and more experience is gathered.

4Summary

The Chinese government has made efforts to improve primary health care to its citizens by encouraging the development of general medicine.When there are complex problems in medicine,one strategy is to break the complex problem into its parts and see how each may be addressed.In the above article,I outlined three areas that may be hindering GP development in China and recommended some solutions.At the end,if China is able to envision itself with an efficient health care system lead by established primary care principles and supported by rational regulations,the healthcare systemthat emerges here will eventually be the envy of the world.

(本文編輯：閆行敏)

收稿日期：(2015-11-10)