Characteristics and Workload of Pediatricians in China

Home , Huang Ju, Xinhua Hospital

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 the total number and western regions and urban Procedure of pediatricians to the county’s area and rural according to the Structured questionnaires were in units of 10 000 km2. Similarly, definition of regions specified by the developed by a panel of experts, hospital density comprised the Chinese government. Eastern regions including epidemiologists, ratio of the total number of hospitals are the most developed, whereas pediatricians, hospital directors, and government officials, to be completed online by senior hospital personnel. It was pilot tested in hospitals affiliated with Shanghai Jiao Tong University. The survey was conducted between June 2015 and October 2016. In each province, a senior member of the Society of Pediatrics within the Chinese Medical Association and PS-CMDA were trained by epidemiological investigators.

Characteristics of Pediatricians and Hospitals In China, a pediatrician is defined as a physician certified by the National Health Commission of the People’s Republic of China and licensed as specializing in medical care for children. Information on pediatricians included age, highest education level (postgraduate, undergraduate, junior college, or polytechnic school), and professional title (none, resident, attending, or staff physician). Pediatricians’ workloads were calculated separately for outpatient care (pediatric outpatient visits/ pediatrician/year) and inpatient care (pediatric beds 3 turnover rate/ pediatrician/year). The pediatrician dropout ratio was defined as the number of pediatricians who had left the profession (those who still practiced as pediatricians in another FIGURE 2 hospital were excluded) in the Spatial clusters (hot spots or cold spots) of the number of pediatricians in 2733 counties in China previous 3 years divided by the total (2014) based on the Getis-Ord Gi* statistic. The hot spots reveal the spatial clusters with many number of pediatricians in the pediatricians. The cold spots reveal the spatial clusters with a small number of pediatricians.

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 144, number 1, July 2019 3 western regions are the least developed. (0.8) 1108 188 (0.3) Statistical Analysis We conducted a comprehensive (35.4) (85.7) 47 928 description of characteristics of the

54 214) hospital and pediatricians. The Gini 5 ﬁ

N coef cient, the most commonly used measure of inequality, was calculated (32.2) 43 613 to evaluate regional inequalities of the distribution of pediatricians in regional child population using the 10,11

(31.6) Lorenz curve. In this study, weights accounting for the sampling design of the survey were applied in all analyses. All statistical analyses 442 (2.1) 42 875 were performed by using SAS software (version 9.4; SAS Institute, P , 4006

(18.7) Inc, Cary, NC). A value of .05 for 2-tailed tests was considered 2129; 3.9%) Total ( ﬁ

5 statistically signi cant. N (52.9) 11 349 RESULTS In 2014, China had a total of 135 524 pediatricians and 54 214 hospitals (26.3) providing pediatric care (Fig 1). The median PPTC number was 0.41 (25th

percentile [P25]–75th percentile [P75]: 415 (0.4) 5638 140 (0.3) 166 (7.8) 1096 (51.5) 830 (39.0) 37 (1.7) 1846 (3.5) 5702 (10.5) 46 478 0.211–0.79). On the basis of the study, 3 main challenges in the current pediatric care system were found. (42.0) (87.8) 43 922 52 009; 95.9%) MCHs ( 5

N Uneven Development of the Pediatric Care System (30.2) 31 606 The distributions of hospitals and pediatricians were highly skewed,

at 2.7 (P25–P75:0–7.5) and 15.0 General Hospitals ( (P25–P75: 6.6–46.2) on average per (27.4) 2 10 000 km and 0.59 (P25–P75: 0.43–0.81) and 0.23 (P25–P75:

76; 0.18–0.38) on average per 1000 5 children. Substantial geographic N disparities in the distribution of pediatricians were observed (Fig 2), 0.2%) 658 (6.9) 251 (2.6) 28 607 with a Gini coefﬁcient of 0.61. East 9539 (7.0) 104 550 (77.2) 21 435 (15.8) 135 524 s Hospitals ( ’

Public Private Public Private Public Privatecoast provinces Public of China Private have a per capita gross domestic product twice 8630 (90.5) Tertiary Secondary Tertiary Secondary Primary Tertiary Secondary Primary Tertiary Secondary Primary as high as that of west inland provinces, and the corresponding

n PPTC numbers are 1.0 and 0.30, (%) 51 (67.1) 14 (18.4) 11 (14.5) 1629 (3.1) 4592 (8.8) 45 648 9 n respectively. Likewise, the average Characteristics of Pediatricians and Hospitals With Pediatric Care Services in China cation Children 60 20 18 22 21 19 17 20 19 18 25 20 21 19 18 21 45 28 25 25 27 31 40 26 30 35 40 29 27 32 39 27

ﬁ PPTC number is 0.62 in urban areas – – 60 5 1 27 5 4 5 14 3 3 2 8 5 3 5 14 35 47 56 26 47 46 38 40 48 44 33 42 47 46 38 38 (%) $ 45 EasternCentralWesternUrbanRural 55 24 21 43 100 21Eastern 0 36Central 55 86Western 18Urban 27 14Rural 44 64 55 29 25, 27 20 3635 84 51 100 40 23 28 0 26 16 32 72 89 34 30 6 22 11 30 66 47 40 74 52 23 29 24 26 35 13 85 77 41 42 51 15 30 31 29 27 49 30 90 44 35 33 70 27 29 10 32 67 30 33 28 21 35 12 70 67 37 45 61 62 29 28 27 8 39 30 71 94 42 44 76 25 29 6 33 27 24 42 85 36 39 28 36 15 29 58 32 44 26 34 30 41 15 74 66 30 48 40 76 23 54 28 24 24 33 90 77 13 41 57 31 10 28 43 34 43 28 66 29 29 59 26 15 71 70 30 PostgraduateUndergraduate 50 48versus 6 69 0.39 in 66 7 rural 65regions, 30 71and 3 the 39 1 49 6 73 18 60 4 49 1 65 10 63 33 68 4 40 1 59 8 Hospitals, Region, % Region, % Pediatricians, Age, % Education,% Classi

TABLE 1 infant and child mortality rates are

Downloaded from www.aappublications.org/news by guest on September 28, 2021 4 ZHANG et al FIGURE 3 Pediatricians’ education levels in 31 provinces, autonomous regions, and metropolitan cities in China (2014). twice as high in rural areas as in children’s hospitals (7.0%). Unlike the polytechnic school education after urban regions.12 pediatric care system, the distribution high school. Great regional of MCHs, accounting for ∼15.8% of inequalities were also demonstrated Most pediatricians (77.2%) worked in total pediatricians, was comparatively in pediatricians’ overall educational general hospitals that provide even. The Gini coefﬁcient of MCH levels, with pediatricians with higher pediatric services. The trend is distribution was only 0.20 per education levels clustered in well- similar for the distribution of these children’s population, comprising developed regions such as Beijing and hospitals. Tertiary hospitals were one-third of general hospitals. Shanghai where 47.3% and 37.8% of concentrated in urban areas (85.0%) pediatricians, respectively, had and eastern China (44.4%) (Tables 1 Lack of Appropriately Trained and a postgraduate degree (Fig 3). ﬁ and 2), whereas primary hospitals Satis ed Pediatricians Conversely, 165 counties (6.0%) did were mainly in rural areas (77.0%) Regarding educational level, 32% of not have a single pediatrician with and western China (40.0%). A small pediatricians had only completed a bachelor’s degree. In rural areas, proportion of pediatricians worked in 3 years of junior college or half the pediatricians had only 3 years

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 144, number 1, July 2019 5 of medical training after high school. In tertiary hospitals, 95% to 98% of (0.8) 1108 pediatricians had a bachelor’s degree or higher. In contrast, 50% to 60% of pediatricians in primary hospitals (35.4) 47 928 were graduates from junior colleges 135 524) and polytechnic schools. 5 N Overall, pediatricians in China were (32.2) 43 613 young; two-thirds of pediatrician were ,45 years of age. Resident, junior, and senior attending

(31.6) ∼ 42 875 pediatricians accounted for 20%, 30%, and 40% of all pediatricians, respectively. In the past 3 years, 442 (2.1) 12.6% of pediatricians (17 022), most of whom were young doctors, had left their jobs. The tertiary children’s 4006 (18.7) hospitals had the lowest dropout rate

21 435; 15.8%) Total ( (5.0%). 5 N (52.9)

11 349 Unmet Demand for Pediatric Care The total outpatient, emergency, and inpatient pediatric visits recorded in 5638 (26.3) 2014 (Table 3) were ∼500 million, 91 million, and 38.6 million, respectively. The pediatricians in tertiary hospitals 415 (0.4) had the heaviest workload, including the highest bed turnover rate and individual outpatient and emergency (42.0) 43 922 104 550; 77.2%) MCHs ( visits per year (Fig 4). 5

N In the last decade, both the number of patient visits and beds in health (30.2) 31 606 care institutions have doubled (Fig 5) in China, whereas that of licensed physicians increased by General Hospitals ( (27.4) 28 607 only 1.5 times. In other words, in a health care reform context in China, although government health 9539; (2.6)

5 expenditure has increased by more

N than 7 times, physicians’ personal workloads have increased by

7.0%) ∼ 658 (6.9) 251 1.3 times on average. s Hospitals ( ’ Public Private Public Private Public Private Public Private 2 25 27 5 26 60 45 9 36 50 25 4 28 59 33 431 44 33 2454 4135 7771 86 364 1155 446 103 3249 5334 8217 222

(90.5) DISCUSSION Tertiary Secondary Tertiary Secondary Primary Tertiary Secondary Primary Tertiary Secondary Primary This study is the ﬁrst national survey of pediatric human resources conducted in China. Pediatricians’ overall educational level was low, n (%) 8630

n and nearly one-third of them did not

n have a bachelor’sdegreeorhigher. Characteristics of Pediatricians and Hospitals Providing Medical Care Services for Children in China cation Children

ﬁ Despite the health care reform in school, ResidentAttending physicianStaff physicianNo. dropouts, 28 37 35 31 40 29 23 35 42 31 35 34 37 40 23 35 55 10 33 43 24 33 37 30 39 44 17 43 42 15 36 39 25 31 35 34 37 41 22 35 54 11 37 40 22 Dropout rate, % 5.0 6.7 13.1 8.6 13.1China, 17.7 physicians 20.7 6.5’ workloads 10.2 have 11.1 23.3 7.6 12.2 17.1 20.0 Junior college and polytechnic Professional title, % Dropout Pediatricians, Classi

TABLE 2 For general hospitals, only those providing pediatric care services were counted. The numbers of hospitals and pediatricians were weighted counts. increased. The dropout rate in the

Downloaded from www.aappublications.org/news by guest on September 28, 2021 6 ZHANG et al FIGURE 4 Outpatient and emergency pediatric care service shares of different types of hospitals in 31 provinces, autonomous regions, and metropolitan citiesin China (2014). last 3 years was higher than 10%, necessitating a net increase of returned to their hometowns to particularly in private and primary 90 000 pediatricians. Many measures build practice, training, research, and hospitals. Strategies may be have been taken to train new advocacy.19 Our hospital in Shanghai developed to target 2 key issues: pediatricians. Because the has been training pediatricians from physician training and retention, and maldistribution of pediatricians western provinces of China since structural reform of the pediatric is generally combined with 2012. After the training, trainees care system. socioeconomic disparities,20 these return to their local hospitals to measures may not prevent trained assume important roles. Pediatrician Training and Retention pediatricians from moving to urban Unfortunately, the current targeted Strategies areas, and rural areas that need training programs are far too small The PPTC number in China (0.40) pediatricians the most may continue and too few to meet the vast needs of fi was half that in Japan (0.93)13 and to bene t little. This is borne out by the whole country, partly because fi a quarter that in the United States evidence from other countries; in there are no nancial incentive or (1.9),14 thus lagging greatly behind Japan in 2004, for example, a new reimbursement mechanisms for the average level of developed postgraduate medical education trainees. countries. Each Chinese pediatrician program was introduced to improve Because China is extremely diverse, takes care of 10 times more patients residency training and optimize a one-size-fits-all approach is than an American pediatrician, clearly distribution, but the distribution 13,17 inappropriate. Based on the high indicating the severe shortage of worsened. dropout rate in primary hospitals, pediatricians in China. The The experience of the African a targeted location-allocation strategy maldistribution and shortage Pediatric Fellowship Program has may be an effective option when of physicians poses a challenge to provided a powerful example of how recruiting new pediatricians to the health systems of many 15–19 to deal with retention. minimize access inequality and countries. Approximately 98% of trainees from balance supply and demand in the The Chinese government’sgoalisto local hospitals finished the program long run.20 However, working in rural increase the ratio to 0.69 by 2020, in an advanced institution and and remote areas is not appealing to

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 144, number 1, July 2019 7 FIGURE 5 The trend of Chinese major health care indexes (1997–2016). Left axis: total population (billion, year-end); number of licensed (assistant) physicians (thousand); number of beds in healthcare institutions (thousand); number of patient visits in healthcare institutions (million); right axis (government health expenditure (million, yuan). most pediatricians and, in the short- lives,21 and family doctors are also were found to be more harmonious term, active deployment of existing encouraged to take care of children. between pediatricians and patients’ human resources may be another families. More interestingly, the media route to address the challenge. In the Structural Reform of the Pediatric coverage on the crisis of the United States, for example, Care System pediatrician shortage in China came the problem of dropout rates was When the spread of “medical dispute from those provinces where reduced by providing part-time proﬁteers” attracted academic and pediatrician resources are more positions targeted at female industrial attention in China, the abundant. In these regions, more than pediatricians who wanted to balance situations in other countries with half of the pediatric workload is their personal and professional a similar number of pediatricians concentrated in tertiary hospitals,

Downloaded from www.aappublications.org/news by guest on September 28, 2021 8 ZHANG et al leading to the perception of preterm birth or low birth weight as a shortage of pediatricians. This is the leading cause of death. The rapid exacerbated by the combination of increase in childhood asthma27 and low fertility and increasing wealth, other allergic disorders, attention- which has led to increasing demands deficit/hyperactivity disorders,28 for high-quality pediatric care.22 The obesity,29 and precocious puberty30 ever-expanding tertiary facilities in requires new knowledge and pediatric care remain insufficient to therapies that are often foreign meet the increasing demand for even to well-trained physicians. The better care nationwide. Therefore, the health care model must change key strategy is to return to the 3- accordingly from a pure medical tiered medical referral system with to a biopsychosocial model. a gatekeeping system like that in the However, most Chinese pediatricians are United Kingdom. Unfortunately, many not yet prepared for this. In Switzerland primary care facilities and personnel and the United States, family doctors in pediatric services are broken take care of ∼20% of the child because of negligence over the past workload.31,32 Thus, training traditional decade, and the availability of MCH physicians as qualified secondary pediatric care has shrunk pediatricians represents both an severely.23 Because the pediatric opportunity and a challenge. workload increased in the last decade when children’s numbers remained Furthermore, the physician fee stable in China, we can foresee that, structure must also match the without gatekeeping, the workload in strategy of regionalizing and tertiary hospitals will continue to optimizing the limited resources. In grow. To rebuild this system, the China, there is no referral system Shanghai government divided the among primary, secondary, and metropolis with nearly 25 million tertiary hospitals. Although most of residents into 5 clusters and is the population is covered by attempting to link up tertiary, secondary, government health insurance, most and primary pediatric care facilities to patients pay a portion of medical regionalize child health care and costs out of pocket, particularly in optimize the utility of high-level outpatient departments and even in resources. Health maintenance and public hospitals, and have the right simple health problems are dealt with at to choose their own provider. Of the local level, and more complicated greater concern are the negligible cases are treated at the tertiary level. differences in the already low Physicians at higher-level hospitals take physician fees between hospital turns to provide services and training in levels. This, coupled with the 1-child lower-level clinics to boost quality of family policy, has encouraged s Hospitals General Hospitals MCHs Total ’ care. Family doctors are also families to seek the best care encouraged to take care of children.24 within their reach even for trivial Public Private Public PrivateThese approaches Public are potentially Private Publicproblems. Private With economic applicable to a larger network across development and transportation Tertiary Secondary Tertiary Secondary Primary Tertiary Secondary Primary Tertiary Secondary Primary the urban-rural boundary. convenience, the demand for high- level pediatric care is ever Additionally, there is a special system, increasing. Many parents choose to

1000 per y 8628 524 79MCH, 27 872covering 17 491 24 486 almost 128 5424 theentire 5085 734 137attend 41 924 23 099 a tertiary 25 220 345 center, which is 3

1000 per y 45 925 2366 2006 97 410country. 101 109 189 466 MCH 1101 is 18 705 both 31 887 an 9797 820 162 040 135 362considered 199 263 3927 to provide the best 1000 per y 1598 115 20 19 292 7990 6814 46 868 1511 285 41 21 757 9617 7099 106 3 3 administrative and a health care care at a low price similar to that system providing health maintenance of lower-level hospitals. and basic health care.25,26 However, Furthermore, pediatricians’ job Characteristics of Workloads of Hospitals Providing Medical Care Services for Children in China cation of Workload Children

ﬁ the causes of death and disease satisfaction is disappointingly low

Outpatient visits, Emergency services, Total No. bedsOccupancy rate, %No. outpatients, spectrum 34 45.7 984 2122 45.1 have 558 11.7 also 93 923 37.5 changed 129 945 27.0 155 067 over 1072 5.7 the 17 060 6.5 28 465because 42.2 5389 1486of 23.5 their 145 967 10.5 160 532 low 160 14.0 456 payment 3116 42.2 25.5 10.5 10.3 Outpatient and emergency services Beds and turnover Classi

TABLE 3 For general hospitals, only those providing pediatric care services were counted. The numbers of hospitals andyears. pediatricians were weighted counts. Infection has given way to relative to other specialties, high

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 144, number 1, July 2019 9 workload, and intense patient- No data were available to estimate ACKNOWLEDGMENTS 33 physician relationship. Consequently, accurate numbers of the migrant We thank all contributors who few medical students want to become population at the county level. were not listed as authors, pediatricians and 12.6% of practicing Because migrants generally move including Drs Yuxin Bai, Yu Chen, clinicians are giving up their from rural to urban areas or from less Zhou Fu, Ying Huang, Xuan Kan, professions and moving to other developed to more developed regions, Sitang Gong, Qiang Gu, Fuhai Li, careers. The large income gap between the PPTC number in western regions Yonghong Miao, Minna Shan, Furong pediatricians and other specialists also may have been overestimated. Shi, Huiying Shi, Yun Sun, Min Tan, must be addressed by both market However, only a minority of migrants Zhiliang Tian, Huaping Wu, Yin Xi, force and government policies. are accompanied by children, most of 14 Xiao Zhenghui, Zhenhua Xie, Finally, technologies such as whom are left behind with relatives, Xindong Xue, Jinghui Yang, Yinan electronic medical records, so the number of migrant children is Yang,LiZhang,XiaopingZhang, telemedicine, connected interactive relatively small and unlikely to have Haoquan Zhou, Fabao Zhang, and fl medicine networks, and even artificial in uenced the analysis. Zhongcheng Luo. intelligence may, to some degree, resolve the challenge of insufficient CONCLUSIONS and uneven distribution of pediatric resources and facilitate training. Considering the unequal distribution ABBREVIATIONS and general low education level of MCH: maternal and child health Limitations Chinese pediatricians, it may be more care hospital First, although the R was high effective to reframe the structure for PPTC: pediatricians per 1000 (91.7%), a systematic response bias is pediatricians than to increase the children possible. However, hospitals that did enrollment of young physicians. With PS-CMDA: Pediatric Society of not respond were scattered across the right policy and emphasis on Chinese Medical the country and across levels, which training, retention, and reform, child Doctors Association suggests this is not the case. Second, health can be further improved to R: response rate we did not consider migrant workers. a higher level in the near future.

hDepartment of Pediatrics, Shanxi Children’s Hospital and Shanxi Medical University, Taiyuan, China; iDepartment of Pediatrics, Tianjin Medical University General Hospital, Tianjin, China; jDepartment of Pediatrics, Affiliated Hospital of Southwest Medical University, Luzhou, China; kDepartment of Pediatrics, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; lDepartment of Pediatrics, The First Affiliated Hospital of Guangxi Medical University, Nanning, China; mDepartment of Pediatrics, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China; nDepartment of Pediatrics, Beijing Children’s Hospital at Capital Medical University, Beijing, China; oDepartment of Pediatrics, Peking Union Medical College Hospital, Beijing, China; pDepartment of Pediatrics, The First Hospital of Jilin University, Changchun, China; qDepartment of Pediatrics, West China Women’s and Children’s Hospital, Chengdu, China; rDepartment of Pediatrics, Tangdu Hospital of the Fourth Military Medical University, Xian, China; sDepartment of Pediatrics, Maternal and Child Health Care Hospital of Hainan Province, Haikou, China; tDepartment of Pediatrics, Fujian Provincial Maternity and Children’s Hospital of Fujian Medical University, Fuzhou, China; uDepartment of Pediatrics, The Second Affiliated Hospital of Harbin Medical University, Harbin, China; vDepartment of Pediatrics, Inner Mongolia Autonomous Region People’s Hospital, Hohhot, China; wDepartment of Pediatrics, Hunan Province People’s Hospital, Changsha, China; xSchool of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa, Ottawa, Canada; and zInstitute for Global Health, University College London, London, United Kingdom Drs Y. Zhang, Huang, Zhou, X. Zhang, Ke, and K. Sun contributed equally to the study, conceived and designed the study, collected data, and reviewed and revised the manuscript; Drs Y. Zhang, Huang, X. Zhang, and Ke prepared an analytical plan, analyzed data, and drafted the initial manuscript; Drs Z. Wang, J. Zhang, Little, and Hesketh collaborated in the revision and interpretation of the data and results, and reviewed and revised the manuscript; Drs Chen, Dong,Du,Fang,Feng,Fu,He,G.Huang,S.Huang,Ju,Gao,L.Li,T.Li,Y.Li,G.Liu,W.Liu,Luo,Nong,Pan,Shen,Song,J.Sun,Mu,T.Wang,B.Wang,Xiang,C.Yang, S. Yang, Zhao, H. Zhu, and Y. Zhu were involved in data collection, manuscript review, and revision; and all authors commented on the manuscript and approved the final manuscript as submitted. DOI: https://doi.org/10.1542/peds.2018-3532 Accepted for publication Mar 15, 2019 Address correspondence to Kun Sun, MD, PhD, Department of Pediatrics, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kongjiang Rd, Shanghai, China 200092. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2019 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Downloaded from www.aappublications.org/news by guest on September 28, 2021 10 ZHANG et al COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1131.

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Downloaded from www.aappublications.org/news by guest on September 28, 2021 Characteristics and Workload of Pediatricians in China Yongjun Zhang, Lisu Huang, Xin Zhou, Xi Zhang, Zheng Ke, Zhaoxi Wang, Qiang Chen, Xiangyu Dong, Lizhong Du, Jianpei Fang, Xing Feng, Jianhua Fu, Zhixu He, Guoying Huang, Songming Huang, Xiuli Ju, Li Gao, Li Li, Tingyu Li, Yarui Li, Geli Liu, Wenjun Liu, Xiaoping Luo, Guangming Nong, Jiahua Pan, Kunling Shen, Hongmei Song, Jinghui Sun, Dezhi Mu, Tianyou Wang, Baoxi Wang, Wei Xiang, Changyi Yang, Shufen Yang, Zhengyan Zhao, Hua Zhu, Yimin Zhu, Jun Zhang, Julian Little, Therese Hesketh and Kun Sun Pediatrics 2019;144; DOI: 10.1542/peds.2018-3532 originally published online June 28, 2019;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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