Training Pathways to Working As a General Practitioner in China Siqing Lian, MD; Qi Chen, Phd; Mi Yao, MD; Chunhua Chi; Michael D

SPECIAL ARTICLE

Training Pathways to Working as a General Practitioner in China Siqing Lian, MD; Qi Chen, PhD; Mi Yao, MD; Chunhua Chi; Michael D. Fetters, MD, MPH, MA

BACKGROUND AND OBJECTIVES: To achieve the goal of 300,000 general In China, a contemporary issue in practitioners by 2020—an increase of 215,200 in a decade—China is utiliz- family medicine literature concerns ing multiple training pathways. To comprehensively illustrate general practi- the rigor and quality needed for ed- tioner training strategies in China, this article introduces and describes these ucating such a massive increase in pathways. GPs. Wu, et al identify significant METHODS: We used descriptive policy analysis. This involved taking an inven- differences in the educational qualifications of primary care practitioners tory of existing literature and source documents and developing a model to il- 4 lustrate pathways for training general practice physicians. relative to geographic distribution. They report that the percentage of RESULTS: The rural doctor pathway represents rural clinicians who had only GPs with 3 or more years of clini- basic training and practiced multiple years prior to training reforms. The 3+2 cal training from 2005 to 2013 was pathway to assistant general practitioners requires 3 years of junior college at least 20% higher in urban areas and 2 years of clinical training. The transfer pathway for current physicians re- than rural areas. Based on 2016 Na- quires 1-2 years of training. The 5+3 pathway comprises 5 years of bachelor tional Health and Family Planning of science degree training in clinical medicine and 3 years of standardized res- Commission data, only 0.2% of rural idency training. Despite the development of advanced degree programs, their doctors in village clinics hold a BS use remains limited. degree in medicine, while 44.3% of CONCLUSIONS: These pathways illustrate significant heterogeneity in train- GPs in Chinese community health ing of general practitioners. Training ranges from a 2-year technical degree centers hold a BS in medicine.5 to a doctorate with research. Emphasis on the 5+3 track shows promise for Improved teaching quality has China’s goals of improved quality and new goal of 500,000 additional general been noted as one of the key issues practitioners by 2030. for advancing general practice as a specialty in China. Based on experi- (Fam Med. 2019;51(3):262-70.) ence training more than 1,000 gen- doi: 10.22454/FamMed.2019.329090 eral practice trainers and 4,000 GPs from 30 provinces in China through a collaboration between the Uni- s the world’s largest coun- 2020.2 Achieving this goal would re- versity of Birmingham and Peking try, the policy initiatives de- quire an increase of approximately University of Health Sciences, a pre- Avoted to developing family 215,200 GPs in a decade. Efforts to vious report suggests three priori- medicine (hereafter termed “gen- achieve this goal have progressed, ties for GP training: (1) increasing eral practice” [the closest transla- as illustrated by data suggesting tion of the Chinese word quánkē there were 209,000 in total, or 1.5 2 From Peking University First Hospital, Beijing, yīxué]), in the second decade of the GPs per 10,000 population in 2016. China (Drs Lian and Chi); Institute for Medical 21st century in China are unprec- On January 24, 2018, the Chinese Humanities, Peking University Health Science edented. In 2010, when there were State Council announced a new Center, Beijing, China (Dr Chen); Beijing Xicheng District Xinjiekou Community Health approximately 84,800 general prac- goal of 700,000 total GPs in China Service Center, Beijing, China (Dr Yao); and titioners (GPs),1 the government an- (5 per 10,000 by 2030), an additional Department of Family Medicine, University nounced a goal of achieving 300,000, increase of 500,000 over a 10-year of Michigan, and the Peking University 3 Health Science Center Institute for Medical or 2-3 GPs per 10,000 population by period. Humanities, Beijing, China (Dr Fetters).

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the number of GP trainers, (2) im- practice.4 While a helpful overview, attained directly by obtaining a BS proving the quality of care in com- their introduction does not provide in medicine or graduate degree in munity health centers where GPs full details about the complexity of medicine and completing residency typically work, and (3) transitioning GP training in China. training. Prescribing privileges are to a competency-based rather than In this study, we describe the separate from certification as an as- knowledge-based curriculum.6 training pathways to general prac- sistant physician. Wu, et al illustrate significant tice in detail, and how these path- public trepidation with the quality ways contribute to fulfilling the Pathways to Working in General of training.7 They conducted a rig- aggressive policy of creating access Practice orous mixed-methods study using to a GP for the people of China. Figure 1 is cross-linked with Table focus groups and survey methodol- 2 to illustrate the multiple path- ogy in Zhejiang, China, one of the Methods ways to general practice. Although earliest health reform pilot cities im- We used a descriptive policy analy- there are many pathways, the train- plementing general practice. Their sis approach utilizing three relevant ing intensity varies dramatically. qualitative findings illustrate signif- steps as described by Patton and Sa- Becoming a GP does require first icant distrust of community health wicki12: (1) an inventory phase, (2) a completing elementary and middle services, with the public consider- constrained search for alternatives, school. From this common starting ing them little more than drug dis- and (3) preparation of the findings point, many pathways emerge. pensaries, and viewing practitioners for dissemination. The pathways (ie, as incompetent even for the care of outcomes), emphasize the observed Terms Used for Describing chronic diseases such as hyperten- policy outcome relative to the impor- Generalist Physicians and sion and diabetes. Participants in the tance of teaching GPs. To elucidate Assistant Physicians in China study7 pejoratively equated commu- the various pathways of training for Grasping the Chinese training sys- nity health services to the system general practice, in the inventory tem requires an understanding of of “barefoot doctors” (chìjiǎo yīshēng), phase we examined existing litera- terminology used by the Chinese a system of low-skilled practitio- ture and searched government and government (Table 1). A rural GP ners with little more than a para- university websites for regulations can refer to both GPs and assis- medic’s training who were deployed and policies, and conducted multiple tant GPs.15 The system produces during the cultural revolution (Ta- follow-up searches for variations and assistant GPs (akin to paramed- ble 1).8-11 Another factor complicat- clarifications. For dissemination, we ic/physician assistant) under the ing acceptance of general practice developed a figure detailing the vari- 3+2 training system, by 3 years of can be found in public preferences ous pathways, explicated the find- medical sciences curriculum plus 2 for hospital care. The Wu, et al sur- ings with supporting tables, and years clinical training (Table 1).16-18 vey of 1,248 resondents7 found dis- interpreted the findings to illustrate The system prepares physician GPs trust and lack of confidence in GPs, how the identified pathways reflect through the 5+3 training system (Ta- and patient demand was much high- Chinese policy.13 ble 1); a 5-year bachelor of science er for hospital-based services than degree in medicine plus 3 years of outpatient services. Lack of consis- Results clinical training (residency).16-19 tent training of GPs, and training Development of a Comprehensive To sit for the medical certifica- through multiple pathways devel- Overview of the Pathways to tion examination, assistant GPs oped by the government may partly General Practice must work 5 years as a clinician af- account for lack of public trust and Figure 1 provides a detailed pre- ter a vocational high school degree, confidence. sentation of eight major pathways while graduates with a BS in medi- that historically and currently can cine must work as a clinician for 1 Training Pathways to be followed to become a GP in Chi- year.20 A general practice assistant General Practice in China na. Table 1 provides definitions of with a junior college degree who ob- Wu, et al depict three general prac- terminology needed for understand- tains medical certification and com- tice training pathways: (1) posttrans- ing the system.14 Rural doctors can pletes job transfer training earns the fer training for licensed physicians or only practice in designated rural ar- title of GP and the privilege to pre- assistant doctors to become a GP; (2) eas. They are not necessarily GPs, scribe anywhere in mainland Chi- general practice training involving a although they can be. Assistant doc- na.21 A general practice assistant 5-year undergraduate program and tors with training can become assis- with a vocational high school de- 3 years of residency training, and (3) tant GPs, and with further training gree who obtains medical certifica- family medicine undergraduate edu- and certification they can acquire GP tion earns the privilege to prescribe, cation preparing students for rural status (Table 1). GP status can be but only in rural areas.22

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Figure 1: China’s Multiple Pathways to Working in General Practice

GP Pathway Other Physician Rural Service Pathways Pathway to GP

High school (3 yrs) Vocational high school (3 yrs) High school (3 yrs) Licensed doctors working in community University/ a Junior college (3 yrs) University/BS (5 yrs) PhD course of BS with GP clinical training and health facilities focus (5 yrs) Basic GP Assistant coursework that Worked training (2 yrs) GP residency GP master depends on 20+ years training course and institution. Possible a in rural 3 yrs residency but not common for community GP Assistant* GP training 3 yrs GP health (vocational Assistant* facility and high school (junior college Job PhD course (3 has degree) degree)* transfer Master’s yrs) and fulfill engaged in a training ongoing program required Clinical work Clinical work training research (5 yrs) (2 yrs) achievements a b Job transfer training b a b b 7) 8) Work as GP 1) Work as 2) Work as 3) Work as 4) Work as 5) Work as 6) Work as Work as GP (PhD) (various degrees) rural GP rural rural GP GP (junior GP (BS) GP (MS) (BS in GP) doctor (vocational college * Can prescribe in rural areas, but cannot prescribe in urban settings though (“grand- high school degree) can see patients if supervised fathered”) degree) a After Jan. 1, 2011, only permitted if graduate works in village clinic b Optional advanced training Note: 1-8 correspond to items in Table 2.

Pathway 1: Designated prescribe medications. After complet- degree for medicine, (2) worked more Undergraduate Medical Degree ing 6 years of service in designated than 20 years in a rural health de- Focused on General Practice and rural areas, these GPs can work in partment, or (3) participated in Mandatory Rural Service both rural and urban settings. Wu, a training program and earned a Pathway et al report this pathway as unsuc- training certificate.23 These rural This pathway involves a free uni- cessful in promoting student interest doctors can prescribe medicines in- versity-level medical education for in general practice since a majority cluded in an official list approved for high school graduates who are usu- of students plan careers other than prescription by rural doctors.21 The ally from poor rural backgrounds, general practice.4 government instituted a requirement and leads to an undergraduate BS for rural practitioners to pass the degree in medicine.4 After complet- Pathway 2: Grandfathered Rural examination for a Physician Assis- ing the 5-year university medical ed- Doctors tant Medical Certificate in 1999, but ucation program, graduates need to While not Chinese, we use the term many rural doctors could not pass practice in designated rural areas “grandfathered” to describe this the examination. Requirements for for at least 6 years (or pay a heavy pathway, as many use this term rural practice became stricter with penalty). However, 3 years of clin- in English. This historically-rooted release of the Rural Doctor Practice ical (residency) training count to- pathway describes how practitio- Regulations issued August 2, 2005 wards the required 6 years.4 This ners of various backgrounds persist that dictates all rural doctors need 5-year university program for a BS and become certified rural doctors. to obtain the Practicing Physician in medicine emphasizes family med- Some rural practitioners, both those Assistant Qualification Examination icine/general practice.4 According to who originally trained as barefoot (Zhíyè zhùlī yīshī zīgé kǎoshì) certifi- Chinese regulations,20,21 after work- doctors, and others who completed cate.23 Since January 1, 2011,15 phy- ing for 1 year after medical school medical studies before entering ru- sicians already working in a rural graduation (minimum BS), train- ral practice, continue practicing in setting also need to pass the Rural ees who obtain the Practicing Phy- rural China today. Physician Practice Certificate every sician Qualification Examination Designation as a rural doctor14 re- 5 years to continue clinical practice. (Zhíyè yīshī zīgé rènzhèng kǎoshì) cer- quires one of three qualifications: (1) tification can practice medicine and higher than vocational high school

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Table 1: Terminology and Definitions Used in the Chinese GP Training System Chinese English Characters Definition (Pinyin) Assistant 助理医师 Refers to an entry level health provider who has trained for two years, and is akin to doctor (zhùlǐ yīshī) a paramedic or physician’s assistant. They can assist a variety of doctors. 全科助理医师 Describes an assistant doctor who has completed required training, and passed a Assistant GP (quánkē zhùlǐ qualifying examination to certify as an assistant general practitioner. yīshī) Refers to a health provider trained who trained in entry level primary care services 赤脚医生 during the cultural revolution. Barefoot doctors were low-skilled practitioners with Barefoot equivalent of paramedic’s training.11 Neither barefoot (metaphor for peasant) nor doctor (chìjiǎo yīshēng) doctors (more broadly meaning a health provider), they provided basic acute care, chronic care and preventive services in rural villages.

Describes the system that was designed to deliver basic health in rural villages. 赤脚医生系统 Barefoot It lasted officially from 1968 until 1985 when the Ministry of Health cancelled the doctor system (chìjiǎo yīshēng barefoot doctor title after collapse of medical cooperatives system. At one point, an xìtǒng) estimated two-million peasants were in training as barefoot doctors.11

Describes a practitioner who has trained as 1) a medical student and completed General 全科医师(quánkē residency in general practice, 2) an entry level practitioner who has qualified as a practice doctor, yīshī) GP based on job retraining, or 3) a licensed physician who undergoes job retraining also GP primarily to become a GP trainer.4

乡村医生 Refers to practitioners who have earned a license only to practice in designated rural areas/villages. They are not necessarily GPs. Some have “grandfathered” from Rural doctors (xiāngcūn many years of practice in rural villages if they have passed required certification yīshēng) examinations. Indicates the system of training to become an assistant general practitioner. Derives from required completion of vocational high school training featuring a curriculum 3+2 training on medical sciences (3 years), or a junior college degree (3 years) plus 2 years of 3+2 system clinical training. With further training and licensure, a vocational high school trainee can become a rural GP, while a junior college trainee can ultimately practice as an unrestricted GP. Represents the system preparing GPs with a minimum of a 5-year bachelor of science 5+3 training (BS) degree in medicine plus 3 years of clinical training (residency). The notation 5+3 system includes those obtaining a master of science (MS) degree or doctor of philosophy degree (PhD) in general practice. Practicing 执业医师资格认 Physician 证考试 The licensure examination for practicing the full scope of medicine including Qualification (Zhíyè yīshī zīgé prescribing of medications. Examination rènzhèng kǎoshì) (PPQE)

Practicing 执业助理医师资 Physician 格考试 Assistant (Zhíyè zhùlǐ yīshī The licensure examination required for practicing as a physician assistant. Qualification zīgé kǎoshì) Examination (PPAQE)

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Table 2: Eight Pathways and Variations to General Practice in China # in Restrictions/ Pathway Primary Degree Description Can Prescribe? Figure 1 Stipulations Obligatory 6 Undergraduate BS 1 University/BS Bachelor’s degree course years as rural Yes degree with GP focus GP Doctor qualification Rural practice Grandfather route 2 based on Rural clinic doctor Yes only practice experience Rural GP with Rural practice Vocational high Basic Assistant GP training Yes, but only in vocational school 3.1 restricted as school degree for 2 years rural setting degree Assistant GP After 5 years as rural Rural practice Assistant GP, can take 3.2 independently as Yes optional job transfer training rural GP for GP qualifications Yes, unsupervised if works in rural GP with junior Junior college Take Basic Assistant GP Assistant GP location, but only college degree 4.1 degree training for 2 years unrestricted with supervision through 3+2 pathway in non-rural settings Can practice After 2 years as Assistant GP, independently Junior college 4.2 can take job transfer training without Yes degree for GP qualification restriction to rural area GP with BS through Bachelor of 5 Residency training 3 years GP unrestricted Yes 5+3 pathway Science work as GP with BS for 3 GP with MS through 6.1 GP with MS years then take 2 years MS GP unrestricted Yes 5+3 pathway course MS combined clinical practice 6.2 GP with MS GP unrestricted Yes plus coursework for 3 years GP with PhD Clinical practice combined 7.1-3 GP with PhD GP unrestricted Yes through 5+3 pathway with coursework for 3 years GP unrestricted, can continue in GP previously a GP qualification Rural clinic GP practice/ own specialty licensed physician 8 added to Yes trainer or other specialist also. Enables with various degrees previous degree service as GP trainer.

Note: Items 1-8 correspond with Figure 1.

Pathway 3: Vocational High with a vocational high school degree According to the Practicing Physi- School Degree to General can only practice in rural settings. cian Law20 and Prescription Manage- Practitioner Assistant and For an applicant with a vocational ment Procedures requirements, an Optionally to Rural General high school medical degree seeking applicant needs to pass the Practic- Practitioner (3+2 Designation) to qualify as a rural GP, regulations ing Physician Assistant Qualifica- Pathway 3.1: Assistant Gener- stipulate completion of 2 years of tion Examination and meet facilities al Practitioner With Vocation- basic assistant GP training.25 The management requirements27 to qual- al High School Degree in Rural training includes 82 weeks of clin- ify to prescribe medications in a ru- Area (3+2 Designation). According ical training, 16 weeks of practice ral setting.21 to the Secondary Vocational School in community health facilities, and Professional Catalogue,24 graduates 2 weeks of theoretical learning.26

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Pathway 3.2: Rural General Pathway 5: General Practitioner Pathway 7: General Practitioner Practitioner With a Vocational With Bachelor of Science degree With a Doctor of Philosophy High School Degree (3+2 Desig- (5+3) Pathway 7.1: General Practitio- nation). With sufficient training, Becoming a GP with an undergrad- ner With MS Works First, Then assistant GPs can practice indepen- uate BS degree in medicine repre- Completes PhD Program. A grad- dently in designated rural areas. Af- sents the main pathway under the uate with an MS who works clinical- ter working as an assistant GP in a 5+3 system. Passing the Practicing ly as a GP can return to studies for rural setting for 5 years, passing the Physician Qualification Examination a doctoral course and earn a PhD in Practicing Physician Qualification qualifies the GP to independently general practice. Examination qualifies one to practice practice and prescribe medication as a rural GP20 who can prescribe without restriction on location of Pathway 7.2: General Practitio- from the list of rural practice-ap- practice. Residency training includes ner With MS Who Completes proved medications.21 27 months of clinical training at ter- Doctor of Philosophy Program tiary care hospitals and 6 months Directly. A GP with an MS can ad- Pathway 4: Junior College Degree of practice in community health fa- vance directly into a PhD course to Assistant General Practitioner cilities.28 that generally takes 3 additional with Optional Pathway to GP years. At Peking University Health 4.1: Assistant GP With Junior Advanced Degrees in General Science Center, the PhD candidate College Degree (3+2 Designa- Practice. Under the 5+3 system, must complete theoretical learning tion). After completing a junior col- GPs can pursue research train- through course work and certain re- lege degree program, an assistant ing for a master of science (MS) or search requirements.29 GP can qualify as a rural GP by PhD degree in general practice af- completing 2 years of basic assistant ter clinical practice or through com- Pathway 7.3: Combined Degree GP training.25 Passing the Practic- bined degree programs. The number Program From Undergraduate ing Physician Assistant Qualification of participants choosing these path- to Doctor of Philosophy in Gen- Examination earns the privilege to ways remains very small. eral Practice. This comprehensive prescribe medications in rural set- combined degree program involves tings.20,21 This pathway resembles Pathway 6: General Practitioner undergraduate and graduate medi- the pathway for an assistant GP With Master of Science Degree cal coursework, clinical training, and with vocational high school degree, Pathway 6.1: General Practitio- completion of research requirements. but a junior college degree graduate ner With BS in Medicine Works The detailed contents of this path- who earns these qualifications can for 3 Years, Then Completes an way depend on the institution. practice in rural or urban settings. MS Program. According to the re- Chinese regulations permit pre- quirements of Peking University Pathway 8: Transfer Training scribing privileges for rural general Health Science Center, a GP with Pathway for Community practice, though in urban settings, BS in medicine who works for 3 Hospital-Based Physicians to prescribing medications requires su- years can pursue this pathway. The Become General Practitioner pervision.21 program requirements include theo- Trainers retical studies and 1 year of clinical The transfer training pathway al- Pathway 4.2: General Practitio- training at tertiary care hospitals. lows licensed doctors working in ner With Junior College Degree community health facilities to un- (3+2 Designation). According to the Pathway 6.2.: General Practitio- dergo GP transfer training for 1-2 Practicing Physician Law20 and Pre- ner Combined Master of Science years.30 The training lasts more than scription Management Procedures Course and Residency Training. 1 year and includes coursework for requirements,21 working as an assis- In the combined residency and MS more than 1 month, clinic training tant GP in a rural setting for 2 years degree program, a student with a BS more than 10 months, and prima- meets the requirements to take the in medicine can complete a combined ry practice for more than 1 month Practicing Physician Qualification residency and MS program in three as a fellow or intern in a communi- Examination. Passing the examina- years. The master’s course requires ty health center/station. Completing tion earns qualification as a GP with theoretical learning and residency these requirements provides quali- the privilege to independently prac- training. Upon completion of require- fication as a GP30 with full privileg- tice and prescribe medications in ru- ments, graduates obtain a master’s es to prescribe medications.21 After ral and urban settings. degree, postgraduate diploma for the training, most return to their previ- residency training, a medical license, ous posts and become GP trainers and general counseling certificate. in community health facilities.4 This pathway is needed to prepare other

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specialists as GP trainers so they becoming a GP in China. Training Policy3 encourages assistant GPs can teach in general practice depart- ranges from a 2-year technical de- working in rural settings to pursue ments. Within general hospitals in gree (with subsequent additional re- transfer training.32 China, general pratice departments training and some restrictions) to a The aggressive approach of expan- require staffing by five GPs includ- doctorate with research. These find- sion has led to problems in quality. ing a director qualified as a GP.31 ings corroborate and expand upon Public distrust of general practice three pathways described by Wu, et for care even of common problems7 Distribution of Rural Practitio- al: (1) the undergraduate medical ed- looms as a significant challenge. The ners in Village Clinics and ucation for rural practice, here, path- proactive emphasis on the 5+3 mod- Community Health Centers way 1; (2) retraining, here, pathways el of medical education suggests the According to Training Level and 2, 3.2, 4.2, and 8; and (3) residen- next generation of GPs will benefit Location of Practice cy training, here, pathway 5.4 This from better quality training.33 More- To provide a window on the distri- analysis adds the assistant GP path- over, the flexibility in training path- bution of GPs in China according to ways 3.1 and 4.1, and advanced-GP ways to date suggests that faculty the different pathways illustrated in MS and PhD pathways 6.1, 6.2, 7.1, development and professional medi- Figure 1, we examined official gov- 7.2, and 7.3. The details provided cal education can be utilized to im- ernment data from 2015. In 2015, about historical differences and ex- prove the education of GPs who have only 5 years after announcing the plication of the advanced pathways completed less intensive training aggressive policy to more than tri- account for the differences with the previously. ple the size of GPs in a decade, the Wu, et al description.4 While the de- Chinese government reported there scribed research pathways remain Implications for the Training of were 188,649 GPs,5 an increase of new, they represent pathways criti- General Practitioners in China 103,849 GPs in 5 years. While be- cal for general practice’s academic These findings represent critical con- hind pace for achieving the target of advancement. text for medical educators engaged 300,000 GPs in 10 years, the growth This analysis illustrates the vari- in expanding general practice train- was remarkable. ations in the pathways to becoming ing capacity in China. China utilizes Table 3 presents the distribution a GP. These findings suggest signif- multiple pathways that differ from in 2015 of rural practitioners includ- icant flexibility for assistant GPs many countries. International ed- ing doctors and assistant doctors by and licensed physicians working in ucators teaching in China should their training level and practice in community health centers to pursue familiarize themselves with these village clinics or community health training to qualify as GPs. The mul- pathways to frame their teaching. A center in 2015.5 Compared to com- tiple pathways help expound how McKinsey report paints an optimis- munity health centers practitioners the Chinese government has add- tic picture for achieving success in (73,288), practitioners in village clin- ed significant numbers of GPs in a health care reforms, but identifies ics (309,923) numbered more than short time since 2010. These path- as challenges sustainable funding for 4.2 times greater. The table sug- ways further show how aggressive- health care, long-term care and ad- gests some practitioners, presumably ly the Chinese government created vances in institutional capabilities.34 those who grandfathered into prac- pathways and training systems for A focus on training in the communi- ticing, did not even complete a high achieving the laudable goal of rap- ty may yield a better understanding school degree. Vocational high school idly increasing the number of GPs. of community-based training needs35 degree-holding practitioners num- Transfer training provides an and research. bered the greatest among all prac- important quick solution for rap- titioners, accounting for 51.9%. In idly increasing GP numbers, since Overcoming Lack of Trust contrast, 76% of community health retraining requires much less time This analysis illustrating significant center practitioners had a junior col- than training new GPs. Starting at heterogeneity in the quality in GP lege or college degree. While 1,539 the beginning of the training pro- training approaches helps explain practitioners had an MS degree, they cess requires a minimum of 5 years in part why GPs face a significant worked exclusively in community for a GP assistant (3+2 pathway) challenge for earning the public’s health centers. The data convincingly and 8 years (5+3 pathway) for a GP. trust.7,33,36,37 We agree with Wu, et demonstrate higher education levels The government actively encour- al,7 on the need to build on positive of practitioners working in commu- ages transfer training of assistant public perceptions about primary nity health centers than in village GPs to become GPs, eg, pathways 3.1 care providers’ value as a trusted clinics. to 3.2 and 4.1 to 4.2, and for physi- source for referral, drug dispensing, cians in rural community health cen- managing chronic diseases, and pro- Discussion ters to engage in transfer training. viding patient education. Trainees This study provides a detailed rep- For example, the General Practitio- may benefit from discussion on how resentation of eight pathways for ner Training and Use of Incentives to advocate their skills as providers

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of choice for first-contact care to pa- PRESENTATIONS: This study was presented 15. Primary Health Department. Implementation tients. at the Michigan Medicine-Peking University Opinions of the General Office of the State Health Science Center Joint Institute for Council on Further Strengthening the Con- Translational and Clinical Research, Eighth struction of Rural Doctors. (Chinese). 2015. Future Research Annual Symposium, October, 2018. http://www.nhfpc.gov.cn/jws/s3581/201503/02bef Future research could address even ee5e0234bf1bda7a43ef60aaa9b.shtml. Accessed CORRESPONDING AUTHOR: Address corre- July 19, 2019. more comprehensively specific com- spondence to Dr Michael D. Fetters, Depart- 16. National Health Education. Opinions on the petencies and skills of GPs on the ment of Family Medicine, University of Michi- establishment of residents’ standardized train- different pathways relative to the gan, 1018 Fuller Street, Ann Arbor, MI 48104. ing program. (Chinese). [Accessed 2018 Feb 4]. 734-998-4978. [email protected]. health needs of the communities Available from: http://www.gov.cn/gzdt/2014- 01/17/content_2569096.htm. Accessed February served. Changes in medical edu- References 4, 2018 cation and GP curricula will like- 1. Ge Y, Xu J, Zhou Y, Qian D. History and pres- 17. Liu Z. Let more “gatekeepers” guard the health ly continue. Wang, et al report that ent situation of development of general prac- of the people. From People’s Political Consulta- many leading institutions in Chi- tice in China. Chin Gen Pract. 2013;16(7):2201- tive Conference Newspaper. July 9, 2018. na—18 at the time of publication in 2203. 18. Li D. Training doctors for primary care in Chi- 2. Xinghua Z. The speed of General Prac- na: transformation of general practice educa- 2015—were trialing an 8-year med- tion. J Family Med Prim Care. 2016;5(1):1-2. 38 tioner Training raise again. (Chinese). ical curriculum. 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