SPECIAL ARTICLE

Family Training in Honglei Dai, MD, MS; Lizheng Fang, MD; Rebecca A. Malouin, PhD, MPH; Lijuan Huang, MD, MS; Kenneth E. Yokosawa, MD; Guozhen Liu, MD

BACKGROUND AND OBJECTIVES: In 2010, six ministries of the evaluated solely by their mentors. Chinese government jointly issued a plan for building team-based This paper describes the different primary care led by family physicians, prompting the creation of types of family medicine training in new models of family medicine training across the country. The China using sources such as litera- purpose of this paper is to describe examples of existing family ture and Internet reviews from both physician training models in China, to present advantages and dis- China and the United States and di- advantages of the various models, and to present a specific model rect observations from the Chinese of family medicine residency training implemented at the Zhejiang and American faculty involved in University Medical School-affiliated Sir Run Run Shaw Hospital in training programs in China. collaboration with the Michigan State University-affiliated Genesys Regional Medical Center. Primary Care in China (Fam Med 2013;45(5):341-4.) As a result of recent social and eco- nomic development in China and the strong evidence base supporting the he Chinese medical education final written examination offered by relationship between primary care system differs greatly from the national government. Generally, and improved health outcomes, Chi- Tthe American medical educa- over the past 15 years, medical grad- nese health authorities have recog- tion system. Most Chinese medical uates with a 5-year degree work in nized the value and importance of students are recruited directly from rural community while those accessible, continuous, coordinated, high school following a standard- with 7- and 8-year degrees work in and comprehensive care.6-8 Addition- ized college entrance examination. hospitals and become subspecialists. al factors promoting family medi- Students rank colleges and univer- Those with a 3-year degree work un- cine in China include the aging of sities, and are matched based on der a licensed physician but can be- the population, increased urbaniza- merit. The length of post-second- come independent physicians after tion, increased infectious and chron- ary medical training is 3, 5, 7, or 8 several years of practice and success- ic disease, and rising costs of health 1-4 years. Three-year programs are ful completion of a series of exami- care.9 In an effort to achieve better equivalent to a physician assistant nations. Increasingly, students are primary care, the Chinese govern- program in the United States. How- enrolling in 7- and 8-year programs. ment has been heavily investing in ever, few medical schools offer 3-year Until recently, a structured, stan- improving the infrastructure of rural programs. Students with 5 years of dardized residency training program clinics, community health centers, medical education receive a bachelor did not exist for any specialty. Fam- and hospitals. Despite all of these of medicine degree, and those with 7 ily medicine is the first specialty to efforts, consistently high-quality, or 8 years of medical education are begin a 3-year residency program awarded a master’s or doctoral de- similar to an Accreditation Coun- 5 From the Department of Family Medicine, Sir gree in medicine, respectively. cil for Graduate Medical Education Run Run Shaw Hospital, Zhejiang University Irrespective of length of medical (ACGME)-accredited family residen- Medical School, China (Drs Dai, Fang, and education, all are considered medical cy program in the United States. The Huang); Department of Family Medicine and Department of Pediatrics and Human students until they graduate from majority of medical school graduates, Development, Michigan State University (Dr their respective programs. To gradu- including general practitioners, are Malouin); Family Practice Residency Program, ate and practice as an independent trained through an apprenticeship Genesys Regional Family Medicine and Department of Family Medicine, Michigan physician, each student must pass a model, and their competency is State University (Drs Yokosawa and Liu).

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rigorous medical training for family Reform Commission of China im- practicing physicians and physician physicians and other primary care plemented a free training program assistants have been selected by pro- providers is lagging.10 A shortage of for medical students.16 Participat- vincial governments to be retrained. well-trained family physicians and ing medical students must agree to The retraining period is for 1 year other primary care providers in ru- practice in an underserved area for (full-time) or 2 years (part-time) in ral areas and a lack of easily acces- at least 6 years after graduation. The hospital-based family medicine res- sible continuing medical education training is for a 5-year medical de- idency training programs affiliated have posed additional challenges to gree and includes free tuition and ac- with a medical school or universi- improving the quality of care. Conse- commodation and a discounted meal ty. 11,12,19 Financial support for this quently, six ministries of the Chinese plan.1-4 Five thousand medical stu- training is provided by the local and central government jointly issued a dents from 24 provinces, including provincial governments. plan for building family physician- autonomous regions and municipal- The training format includes lec- led primary care teams. ities in the central and western re- tures in small groups, interactive gions of China, have been enrolled case presentation and discussion of Current Models of Family in 51 medical schools through this patients, small-group discussion, Medicine program.17 role playing, simulation training, Although there are several estab- and demonstrations of procedures.13 lished primary care physician de- Retraining Existing Practicing Alternatively, physicians may elect velopment programs nationwide,11-15 Physicians to Become Family supervised self-study following suc- these programs lack uniformity, Physicians cessful completion of all require- consistency in training, and overall According to the 2010 China Health ments within a family medicine quality. Examples of existing models Statistics Yearbook, in 2009, the to- residency department. Retraining include (see Table 1): tal number of practicing physicians of practicing physicians has been and physician assistants in China carried out in , Shanghai, Free Training for Medical was 2,329,206, of which 123,448 or Guangdong, and other areas.11,12,19 Students Serving Underserved 5.3% are family physicians and fam- Regions of China ily physician assistants.18 Standardized Family Medicine To address provider To increase the number of well- Residency Training shortages in rural areas of China, trained, qualified family physicians Medical students interested in fam- particularly in central and west- and to provide high-quality pri- ily medicine, generally from 5-year ern regions, the Development and mary care for rural areas, 50,000 programs, may enter into a family

Table 1: Advantages and Disadvantages of Family Medicine Training Models

Training Models Advantages Disadvantages Free training for medical students • Provides tuition to students from • Absence of practical clinical serving underserved areas underserved areas experience

• Increases medical services in rural and other underserved areas Family doctor retraining • Transitional measure to establish • Family medicine training period is family medicine in the community too short setting • Quality of the training is not • Retrained community physicians standardized and often only have clinical experience and can theoretical or simply a combination of quickly become family physicians and rotations in various specialties serve the community Standardized training after graduation • Standardized postgraduate • Due to inequalities in resident curriculum. salary, in recognition of academic training, and in future employment • Residents are rigorously trained by options, as compared to other medical faculty trained in family medicine. specialties, family medicine residency programs do not currently attract the • Residents benefit from training most competitive students in both inpatient and outpatient settings at the hospital as well as at community health centers

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medicine residency training program formal agreement between the two is the first training program in Chi- following graduation from medical institutions includes a plan for fac- na to collaborate with an ACGME- school. The total length of the train- ulty development for the Chinese accredited family medicine residency ing is 36 months20 and consists of family medicine faculty, intensive training program and has set a goal three parts: (1) didactic instruction training of current Chinese fami- to become the first program in China in family medicine theory and prin- ly medicine residents employed by to be accredited by ACGME interna- ciples of managing common prob- SRRSH, a new standardized curric- tional while simultaneously meeting lems, (2) 1- to 4-month rotations in ulum and rotation schedule for new all requirements of the Ministry of different clinical departments, and family medicine residents at SRRSH, . The program has (3) 40 weeks of rotations in commu- and a family medicine training pro- received recognition from the Minis- nity health centers. Family medi- gram for Chinese community health try of Health as a model family med- cine is taught through daily patient center physicians. icine residency program for China.25 care, classroom and group teaching, During the newly developed and self-study. During rotations in 3-year residency training, residents The Future of Family the hospital, the program provides receive instruction through a one- Medicine Training in China at least a half day per week didac- on-one preceptorship, emphasizing With the increasing number and tic session in the format of lectures, continuity of care and preventive types of family medicine training seminars, and case discussions. Lon- medicine. Students are required to programs in China, the government gitudinal community outpatient meet the six ACGME core compe- has enacted a number of polices training is provided in a communi- tencies, which include patient care, and regulations for family medicine ty health center to ensure students medical knowledge, practice-based training, hoping to establish quality experience continuity of patient learning and improvement, inter- standards across the training pro- care.21-23 Residents work in commu- personal and communication skills, grams. However, many issues per- nity health centers under the super- professionalism, and systems-based sist. First, due to diversity in the vision of a faculty member and log practice. To meet these competencies types of training, currently the title their activities in a book provided by and to provide both inpatient and “family physician” applies to individ- the central government. outpatient clinical experience, full- uals with varying types and lengths time family medicine faculty from of clinical training. In light of this, it The Family Medicine Residency SRRSH supervise residents in three is suggested that medical graduates at Sir Run Run Shaw Hospital clinics. The clinics include a lo- planning to become family physi- Sir Run Run Shaw Hospital cated in SRRSH, a community clinic cians should be required to complete (SRRSH), along with 32 other large in Hangzhou, and a community hos- a 3-year standardized residency, as comprehensive (3A) hospitals and pital in the Hangzhou area. standardized training is essential to 730 medium and small hospitals, The curriculum of the family med- ensure the credentials and quality provides medical services to 54 mil- icine residency program at SRRSH is of family physicians in China. Stan- lion people in the Zhejiang Province similar to that of GRMC. GRMC sent dardization of residency training in of eastern China. SRRSH is the first faculty for 2-month rotations to im- other specialties should also be en- hospital to establish a department of plement the new residency program. couraged to ensure the quality of and family medicine and has been pro- GRMC has supported SRRSH in the to equalize the length of training for viding 3-year, structured family med- development of additional training all specialties. Second, family medi- icine training to three new residents sites and establishment of appropri- cine residents have difficulty find- a year since 2005. Seventeen resi- ate referral agreements between the ing employment following the 3-year dents have participated in the pro- Department of Outpatient and De- residency, as they receive no creden- gram to date. partment of Medical Affairs with- tial or higher degree as a result of In 2010, SRRSH developed a for- in SRRSH. GRMC and MSU have this additional training.10 This dis- mal agreement with the Genesys exchanged faculty, residents, and suades many graduates from enter- Regional Medical Center (GRMC) medical students with SRRSH. Se- ing a standardized residency. Third, affiliated with Michigan State Uni- lect medical students from Zhejiang as a result of the first two issues, versity (MSU). The relationship be- University Medical School partici- the skills and training of family phy- tween SRRSH and GRMC began as pated in an 8-week family medicine sicians who have completed formal a result of an invitation from a del- clerkship sponsored by GRMC and residency programs are not recog- egation of American-Chinese physi- MSU in the United States. nized by patients or other physicians. cians to major hospitals in China. While other Chinese programs The Chinese government should de- The vice-chair of the delegation is have collaborated with various inter- velop policies to promote a cultural a physician at GRMC, and SRRSH national universities to develop fam- shift in how residency-trained fam- was the first hospital to respond to ily medicine residency programs,10,24 ily physicians are viewed. Further, the invitation for collaboration. The the SRRSH family medicine program the government should encourage

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