Training doctors for primary care in China: Transformation of general practice education.

China is known for developing a cadre of "Barefoot Doctors" to address her rural healthcare needs in past. The tradition of barefoot doctors has inspired similar developments in several other countries across world. Recently China has embarked upon an ambitious new mission to create a primary care workforce consisting of trained general practitioners having international standard skillsets. This editorial provides an insight into the current status of policy deliberations with regards to training of primary care doctors and a new surge in general practice education in China.

China's introduction and definition of general practice (GP) can be traced back to 1989, over 20 years ago, when Capital Medical University established the first GP Training Center. The so-called GP system was a status of doctors working in the community, being part of the public and able to offer a helping hand when others were suffering from illness. Hence, they were also called family doctors or family physicians, as part of families and serving as a major provider in China's health management system. The unique attitudes, skills, and knowledge of GPs have qualified them to provide sustained and comprehensive medical care, health maintenance, and prevention services to each family member. In fact, China continues to undergo development and transformation of medical services, with GP fulfilling the population's health requirements. It focuses not only on diseases, but also on health; not only on the human body, but also on psychological and mental aspects; not only on science and technology but also on humanity.

Nevertheless, in reality, in the early days when the GP concept was introduced, General Practitioners could only be found in community hospitals and centers nationwide, and the numbers were relatively few. On June 22, 2011, it was decided that GP system should lead the health system to be established in China at the executive meeting of the State Council of the People's Republic of China PRC. At the meeting on the Work of National Health and Family Planning Commission of the PRC in 2015, it was further specified that the pilots of special position plan for GPs will expand to cover 680 counties in 19 provinces in China stressing on the urgency of training of GP teachers/trainers.

Great efforts have since been put into the training of qualified GPs and family physicians. Nonetheless, the public still lacks the trust to engage with GPs and still prefer to squeeze into Grade III Class A and large hospitals despite long waits, queues, and associated hardships to seek treatment even for minor ailments. It is a psychological conception that hospitals still offer higher quality services.

As an ongoing effort to improve the quality of primary care in China, training centers following International guidelines have been established in many provinces in China. Of significance, an established GP center in Shanghai Zhongshan Hospital of Shanghai Fudan University led by Prof. Zhou Shan Zhu was accredited by WONCA as a certified family medicine training center adhering to WONCA Educational Committee guidelines in 2015. Furthermore, on February 25, 2016, an Expert Committee for Educating and Training of General Practitioners supported by the Ministry of Health and under the administration Chinese Medical Doctor Association was officially founded and held its first meeting in Beijing. Zeng Yixin, Medical Superintendent of Beijing Hospital and Academician of Chinese Academy of Sciences, was elected as the Chairman.

The committee will provide advice and suggestions on policies related to the education and training of GPs in China, setting up basic standards and evaluation indicators for the training of GPs, details of training and evaluation of trainees, inspection of training centers and other matters related to the training of GPs.

Nine expert teams shall be established under the general leadership of the Expert Committee, responsible respectively for policy study, evaluation of training centers, training of teachers and trainers, the “5 + 3” (5 years undergraduate medical education + 3 years structured GP training) training of general practitioners, a “3 + 2” training of assistant GPs, transformation training of practitioners from other specialties, vocational training, development of on-line web-based courses and external communication, promoting research as well as defining roles and responsibilities of GPs. There is a suggestion to establish a GP Department in every Public Hospitals. A 2016 Summit Forum on the Training of GPs and the 13th Scientific Conference of GP and Community Health was held in April to engage national leaders of GP to share their training experiences.

During the most recent “Two Sessions” (Annual Session of the National People's Congress and that of the Chinese People's Political Consultative Conference) 2016, “healthcare reform” again became the buzzword putting GP training into the limelight. Quotes include: “GP is an important step in healthcare reform;” “GP system is the first and foremost step in the pentalogy of healthcare reform. As long as GPs are badly needed and the level of GPs remains to be improved, difficulties in getting medical care will continue to exist!”

China is, therefore, committed to strengthening primary medical care services through training and engagement of trained General Practitioner. With the aging population and modernization of lifestyles in China major changes have taken place in China's disease spectrum as chronic diseases become the main cause of death, replacing the long-regarded infectious diseases. This needs to be addressed and China recognizes these changes call for a downward shifting of the focus of medical services from tertiary, secondary to primary with more attention to preventive healthcare, health management, emotions, and psychological issues in medical care. “GPs can endure such change by helping generalize health-care ideas, strengthen health management, control chronic diseases, diagnose serious diseases at the early stage and correctly deal with diseases.”

Like in other countries, the status and function of GPs have received attentions. China also realizes that strengthening primary medical care means not only the construction of buildings and purchase of equipment but to attract highly qualified GPs to provide primary care and enhance people's trust in primary medical care. I have witnessed greater attention being paid to the issue from the governments at all levels, medical system, and the paramedical staff. There are favorable policies which including training tuition waiver, more structured targeted training, setting enrollment targets and providing appropriate recognition through granting specialist status and titles with associated incentives, as well as career planning.

To quote Zeng Yixin, the new leader in GP who holds a prudent, objective and optimistic attitude toward the GP system being a success. “According to new policies, it will be the development direction for China's health-care service to establish a hierarchical diagnosis and treatment system, require GPs to contract with patients and delegate the responsibility of providing medical service to individual doctors. Judging from the definition, it is to be an excellent policy for relieving difficulties and cutting expenses in getting medical treatment.”

Indeed, the development of GPs in China is growing at a rapidly high speed, with the number of GPs amounting to 145,000 at the end of 2013, increasing by 35,000 compared with that in 2012. Although GPs are still often strangers to patients and families in China, they remain the ones being most familiar with the health of the family members they serve for. These “most familiar strangers” will sooner or later become a member of the family providing family medical care.

We hope this provides encouragement to countries developing and enhancing general practice.