China is a developing country with a population of more than 1.3 billion. With the development of society’s economy and the improvement of the living level, people are demanding higher health care. At the same time, industrialization, urbanization and ecological environment changes more and more factors affecting health, population aging and changes in disease spectrum also put new demands on medical and health services. In the metropolis, difficulties in seeing a doctor and higher cost of seeing a doctor come from skip-level diagnosis and treatment. And this phenomenon stems from the weakness of the ability of primary medical institutions which leads to people’s distrust of primary medical institutions. The construction of basic medical and health personnel team in China lags behind, and the number of qualified general practitioners (GPs) is insufficient, which restricts the improvement of basic medical and health services .
According to the 2018 China Statistical Yearbook, Gansu Province has 26,579 primary health care institutions, 199,155 health workers, and 21,358 rural health workers, lower than the average level in China (30,097, 378,673 and 31,331) . The differential analysis on primary health care capacity showed regional differences among 31 regions in China with medical human resources of primary health care institutions in Gansu Province ranking at 16 . In Gansu, the number of doctors per 1000 people is 2.26, below the average level in China (2.59). And the number of GPs per 10,000 people is only 2.58, far from targeted number. So, qualified GPs of Gansu is inadequate.
A recent study from Stanford medical school and Harvard medical school proved that increasing primary care physicians resulted in decreased mortality. GPs are the main force of the medical team, and also the first doctor to visit when patients seek help for common diseases in American . Barbara Starfield indicated that primary care contributed to prevent illness and death and primary care was associated with a more equitable health distribution among populations, and, therefore, health promoting value of primary care contributed a lot in health care system . China has paid attention to primary care and the training and development of GPs. The standardized training system for residents has been tested in some provinces and cities, such as Sichuan, Shanhai and Beijing [6,7,8]. So far, this system is well implemented and resident physicians enjoy an improvement in clinical ability [9, 10]. In Dec 2013, guidance on the establishment of standardized training system for residents was published by the National Health Commission of the People’s Republic of China and other 7 departments. The standardized training system included 34 majors, including general medicine. According to the guidance, all provinces will comprehensively launch standardized training for residents by 2015, and a standardized training system for residents will be established by 2020. All medical clinicians with bachelor degree and above will receive standardized training for residents .
In China, GPs are called gatekeepers to the health of the inhabitants, who are comprehensive medical talents and undertake prevention, diagnosis and treatment of common and frequently-occurring diseases, referral, rehabilitation, chronic disease management and health management in the primary health care institutions. Therefore, the State Council issued opinions on the reform and improvement of cultivation and incentive mechanism for GPs . Establishing a hierachical medical system and implementing a GP contract service, and the responsibility system for medical and health services to individual doctors are the development direction of China’s medical and health services. By 2020, an energetic GP system will be established in China, and a unified and standardized GP training model, also the “first-time in primary health care institutions” service model will be formed. The goal of two to three qualified GPs per 10,000 inhabitants in urban and rural areas will be achieved. The service level of GPs will be improved to requirements of the basic medical and health service needs of the people. However, there were only 253,000 qualified GPs in China and only 1.81 GPs per 10,000 populations by the end of 2017, far below the health needs of the people .
In 2010, the National Development and Reform Commission and other departments initiated the policy of free training for rural order-oriented medical students, in which, students could enjoy tuition-free education and subsistence allowance in the medical university. They should sign targeted employment agreements with the school, health commission and human resources society before getting admission notices and promise to serve in the rural primary health care institutions for 6 years after graduation. And they will be cultivated according to the GP requirements . After reporting for duty, they participate in the three-year standardized training for residents of GPs, which is included in the six-year service period. During this period, they will be educated for general medicine primary knowledge, primary operational skills and especially dialectic thinking of clinical diagnosis and treatment. It includes 2 years and a half in hospital and 6 months in primary health care institutions with GP clinics. At present, the standardized training for rural order-oriented medical graduates is the main training method of GPs .
Since the implementation of the standardization training for GPs in Gansu Province in 2014, there have been two cohorts GP residents graduated. Therefore, it is necessary to investigate the training situation, work status and satisfaction to improve the training of GPs.