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 qualifi- cations 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). 262 MARCH 2019 • VOL. 51, NO. 3 FAMILY MEDICINE SPECIAL ARTICLE 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 FAMILY MEDICINE VOL. 51, NO. 3 • MARCH 2019 263 SPECIAL ARTICLE 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.