Dr. Cassie Zhou FM Residency at Haikou Municipal Hospital China September, 2014

Objectives To understand: o The medical education system in China o Reforms that will reshape China’s primary health care system o Some of the recent successes and challenges in family medicine training in China

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4 The Current System of Medical Education in China

Primary school (6 years) middle school 3 years high school 3 years College entrance exam Standard 本 科 medical school 5, 6 years BA degree Specialist Lower level 大专 Medical school 3 years Master degree specialist PhD degree specialist High level Fewer Medical school 7-8years Go to a hospital Master education 3 years PhD education, 3 years Go to a hospital hospitals in small towns/ community clinic / countryside Go to a hospital The Chinese Medical Education System: Retraining programs 2-3 years Medical school, 中专 Countryside doctors/or community docs Hx of “Barefoot doctors”

Primary school (6 years) middle school 3 years high school 3 years College entrance exam Standard 本 科 medical school 5, 6 years BA degree Specialist Lower level 大专 Medical school 3 years Master degree specialist PhD degree specialist High level Fewer Medical school 7-8 years Go to a hospital Master education 3 years PhD education, 3 years Go to a hospital hospitals in small towns/ community clinic / countryside Go to a hospital Structured, standardized residency training programs being implemented almost nationally Retraining 2-3 years Medical school, 中专 Countryside doctors/or community docs Residency Hx of “Barefoot doctors”

How did I become a GP? 6 years medical school (1988~1994) Practiced OB/GYN after graduation (1994~2002)  Informal training through apprenticeship  A master degree in OB/ GYN Light FM Residency ( )  Dr. Peter Burgos started it !

8 The Chinese Health Care System

The Chinese Medical System: Brief History Review Traditional Chinese Medicine Western medicine developed the recent 100 years A specialty based system 1950’s-1970’s  Free/inexpensive medical care  Barefoot doctors in countrysides More and more system problems were shown since 1980’s :  High cost with poor care  Medical bills are the number one cause of people getting poor

10 Mrs. Luo’s story 55, F, a famer who lives with her husband in a rural village in south Hainan

11 Luo’s health problems Chronic cough and wheezing for 3 years Uncontrolled hypertension Back pain for 2 weeks

How did Luo Seek Medical Care? Saw the village doctor, was given:  oxygen  IV antibiotics and IV steriod  Tranditional Chinese Cough and wheezing persisted Luo decided to see “better doctors” in city hospitals

How did Luo Seek Medical Care? Took 8-hours night bus to the city Registration first when walk in  >99% Patients Walk-in  Triage themselves  Doctor’s Fee: average 7 Yuan ( 1 USD)

 She carried her own medical records  Records had very few doctor’s notes  Needed to see cardiologist, respiratory and orthopedist  Doctors spent very little time with her, because they needed to see 100 pts a day How Did Luo Seek Medical Care?

 Specialists ordered a lot of tests  She had to borrow money to pay for tests and medicine  no continuity of care Luo had seen about 15 different respiratory specialists for cough  Chronic cough persisted, blood pressure not controlled, back pain continued How Did Luo Seek Medical Care?

Luo’s physical problems  Cough- varient asthma  GERD– could be a trigger to her asthma  HTN—uncontrolled  Back pain Luo’s psycho-social problems  Getting poorer  Lost work capacity  Depressed and anxious

After she saw the family doctor Luo’s outcome:  Asthma ---well controlled with inhaled steriod No more cough  BP well controlled  GERD---improved with PPI  Back pain—resolved with medicine FP care is affordable, but  It is not easily accessible  Luo lost trust in her village doctor,she prefers to see me

1.5 billion precious lives

20 China needs good family doctors

Recent healthcare reform

Successes in primary health care reform 95% of the population covered under some kind of health insurance plan Development of health care records for city and rural residents Free vaccination for children Health management of children aged 0-6 years Health care management of pregnant women Health care management of the elderly Management of chronic diseases (hypertension, Type II diabetes, major psychiatric illnesses) Reporting of communicable diseases including disease outbreaks

24 Family Medicine Training in China

Strong government policies and financial support in FPs training  Recognizing that family medicine is part of China’s future  200 national approved FP training programs  Goal: primary care system be implemented throughout China by ~3 FPs every Chinese citizens  Investing in improving infrastructure of community and countryside clinics.

Tracks of FP training FP residency training ( 5+3) Retraining of exsiting practicing physicians to become FPs (1 year) Training of Assisitant FPs (3+2) Training of FP trainers

Challenges for Primary Care and FP training Low competency of primary care FPs No established referral system Different educational levels and clinical backgrounds Historically: passive teaching and learning Current FP training is not structured to provide comprehensive care  Few role models Family medicine is not an attractive specialty yet

Residency Consulation -2012,Haikou

Dr. Heffron –Teaching Chinese FPs

Visiting our graduate physician

31 Many thanks for you : To journey with… To share your resources… To Encourage…