Characteristics and Workload of Pediatricians in China Yongjun Zhang, MD, PhD,a,aa Lisu Huang, MD, PhD,a,aa Xin Zhou, MD,ab Xi Zhang, PhD,ab Zheng Ke, PhD,ac Zhaoxi Wang, PhD,ad Qiang Chen, MD,ae Xiangyu Dong, MD,af Lizhong Du, MD, PhD,ag Jianpei Fang, MD,ah Xing Feng, MD, PhD,ai Jianhua Fu, MD, PhD,aj Zhixu He, MD,ak Guoying Huang, MD, PhD,b Songming Huang, MD, PhD,c Xiuli Ju, MD,d Li Gao, MD,e Li Li, MD,f Tingyu Li, MD, PhD,g Yarui Li, MD,h Geli Liu, MD,i Wenjun Liu, MD,j Xiaoping Luo, MD, PhD,k Guangming Nong, MD,l Jiahua Pan, MD,m Kunling Shen, MD, PhD,n Hongmei Song, MD,o Jinghui Sun, MD,p Dezhi Mu, MD, PhD,q Tianyou Wang, MD,n Baoxi Wang, MD,r Wei Xiang, MD,s Changyi Yang, MD,t Shufen Yang, MD,u Zhengyan Zhao, MD,ag Hua Zhu, MD,v Yimin Zhu, MD,w Jun Zhang, PhD,aa Julian Little, PhD,x Therese Hesketh, PhD,y,z Kun Sun, MD, PhDa,aa OBJECTIVES: Although it is widely believed that China is facing a major shortage of pediatricians, abstract the real situation of the current national status of pediatric human resources and their working conditions has not been evaluated to date. METHODS: We administered a survey to 54 214 hospitals from all 31 provinces in mainland China from 2015 to 2016. Hospital directors of all secondary and tertiary hospitals with pediatric services and a random sample (10%) of primary hospitals provided information on number of pediatricians and their educational levels, specialties, workloads, dropout rates, and other hospital characteristics. A data set of medical resources and socioeconomic information regarding each region (1997–2016) was constructed from the Chinese National Statistics Bureau. The Gini coefficient was used to describe the geographical distributions of pediatricians and hospitals. RESULTS: There were 135 524 pediatricians in China or ∼4 pediatricians per 10 000 children. Pediatricians’ average educational level was low, with ∼32% having only 3 years of junior college training after high school. The distribution of pediatricians was extremely skewed (Gini coefficient 0.61), and the imbalance of highly educated pediatricians was even more skewed (Gini coefficient 0.68). The dropout rate of pediatricians was 12.6%. Despite an increase in the Chinese government’s financial investment in health over the last decade, physicians have been burdened with a greater workload. CONCLUSIONS: Uneven development of the pediatric care system, inadequately trained pediatricians, low job satisfaction, and unmet demand for pediatric care are the major challenges facing China’s pediatric health care system. ’ aDepartment of Pediatrics, abClinical Research Unit, and aaMinistry of Education–Shanghai Key Laboratory of WHAT S KNOWN ON THIS SUBJECT: China has made great Children’s Environmental Health, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, progress in reducing the infant and ,5-year mortality rate. China; acShanghai MedSci Medical Institute, Shanghai, China; adHarvard Medical School, Harvard University and The pediatric care system plays an important role in Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; improving child health. Recently, the crisis facing pediatric aeDepartment of Pediatrics, Jiangxi Provincial Children’s Hospital, Nanchang, China; afDepartment of Pediatrics, care services in China has garnered much publicity. Lanzhou University Second Hospital, Lanzhou, China; agDepartment of Pediatrics, The Children’s Hospital and School of Medicine and yInstitute for Global Health, Zhejiang University, Hangzhou, China; ahDepartment of WHAT THIS STUDY ADDS: Our study was a national pediatric Pediatrics, Second Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; aiDepartment of Pediatrics, health care survey. It revealed substantial challenges in the Soochow University Affiliated Children’s Hospital, Suzhou, China; ajDepartment of Pediatrics, ShengJing Hospital of pediatric care system, including uneven development, unmet China Medical University, Shenyang, China; akDepartment of Pediatrics, The Affiliated Hospital of Guizhou Medical demand for pediatric care, lack of appropriately trained b University, Guiyang, China; Department of Pediatrics, Children’s Hospital of Fudan University, Shanghai, China; pediatricians, and low job satisfaction. cDepartment of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, China; dDepartment of Pediatrics, Qilu Hospital of Shandong University, Jinan, China; eDepartment of Pediatrics, Henan Province People’s Hospital, Zhengzhou, China; fDepartment of Pediatrics, First People’s Hospital of Yunnan Province, Kunming To cite: Zhang Y, Huang L, Zhou X, et al. Characteristics University of Science and Technology, Kunming, China; gDepartment of Pediatrics, Children’s Hospital of and Workload of Pediatricians in China. Pediatrics. 2019; Chongqing Medical University, Chongqing, China; (Continued) 144(1):e20183532 Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 144, number 1, July 2019:e20183532 ARTICLE China has 279 million children ,18 Doctors Association (PS-CMDA) impossible for the government to years of age, accounting for 15% of reported 831 incidents of serious make and assess scientific policies children worldwide.1 Thus, pediatric medical violence in pediatrics, without investigation. Therefore, we health care represents an enormous including 319 attacks on medical conducted a national survey of national responsibility. In the past 3 to workers and several pediatricians pediatric care resources in China to 4 decades, China has greatly reduced being beaten to death or disabled.3 depict regional variations and provide the mortality rates of infants and Thus, in China, pediatric careers have baseline evidence that will allow children ,5 years of age, from 30.1 become extremely dangerous,7 and policy makers to solve the growing and 36.9, respectively, per 1000 live the difficulty of recruitment and issues of the pediatrician shortage in births in 2000 to 8.1 and 10.7, retention, including the low morale China. respectively, in 2015. Pediatricians among pediatricians, has been play an enormous role in China’s reported. METHODS health care system and comprise Numerous policies have been a core component of the pediatric care implemented to meet the challenges Study Design and Participants resource. Nonetheless, to achieve the of the alarming shortage of This study was commissioned by the national goal of infant and ,5-year pediatricians in China8: (1) The National Health and Family Planning mortality rates of 5 and 6, respectively, Ministry of Health has agreed to Commission and conducted by 2 per 1000 live births by 2030,2 decrease the passing score for the organizations: the Society of pediatric medical care will assume an physician qualification examination Pediatrics within the Chinese Medical increasingly important role. for pediatricians but not for other Association and the PS-CMDA. This specialties, and (2) 8 leading medical national cross-sectional hospital Recently, the crisis facing pediatric schools have reinstated pediatrics as survey covered 31 provinces and care services in China has received an independent discipline in medical 2733 counties in mainland China. considerable publicity.3,4 In some school enrollment. These policies Only 118 (4.1%) counties with small tertiary children’s hospitals, a single have prompted public debates and populations (,100 people) and no physician is typically responsible for concerns regarding the safety of medical services were excluded. 80 to 100 visits per day, with an pediatric care. average of .50 work hours per Hospitals were identified from week.5 Thus, pediatricians’ burnout Despite policy reforms, the quantity, national government records. A total may place both patients and quality, and distribution of of 54 214 hospitals responded to the physicians at risk.6 In 2006 alone, the pediatricians at the national level survey, with a response rate (R)of Pediatric Society of Chinese Medical remain unclear in China, and it is 91.76%. The study included all FIGURE 1 Distribution of pediatricians and hospitals with pediatric services in China 2014. a The primary hospitals selected in this study constituted a random sample from all primary hospitals of the general hospital system. Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 ZHANG et al children’s hospitals (n 5 76; R 5 facility.9 The number of pediatricians to the population number and the 100%) and all maternal and child per 1000 children (PPTC) is area. Data on county size, total health care hospitals (MCHs) (n 5 a common indicator of pediatrician population, pediatric population, 2184; R 5 97.5%; Fig 1). The sample resource availability. In this study, gross domestic product per of primary hospitals (n 5 43 922) “children” were defined as Chinese capita, whether it was urban or was identified by first randomly children ,14 years of age on the rural, and area in square kilometers selecting 50% of the counties in each basis of the Chinese traditional were abstracted independently province and then randomly selecting pediatrician practice and the from the statistical yearbook of 20% of all primary care hospitals in definition from the Chinese each county by 2 researchers. each selected county. A total of 4623 Statistics Bureau.9 The pediatrician We classified the locations of primary hospitals were included. geographical density was calculated hospitals as eastern, central, as the ratio of