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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Interesting Looking into Workings of the Community Health Service
Responding to rapidly changing disease patterns in China
Health System Designs in the US and China
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Kenneth Kushner, Madison, Wisconsin U.S.A. Professor, Department of Family Medicine, University of Wisconsin, Jie Wang
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We were extremely pleased to see this article appear in the Annals as it sheds light on a subject that has generally been opaque to Westerners: the actual workings of the Community Health Services (CHS) in the Peoples’ Republic of China. While many Westerners are aware of the “barefoot doctors” during the Cultural Revolution, we have been struck by how many people are not cognizant of the fact that they have largely been phased out. Similarly, while there is ever growing interest in traditional Chinese medicine in the West, very little has been written about how it is actually employed in the CHS. Yang et al have made a significant contribution to the English language literature by explaining how the current health reform policies are being implemented in China as well as some the challenges that will need to be overcome. The current Chinese health care reforms were implemented in 2005. We were present when Dr. Liang, one of the authors of Yang et al, announced the new policies to an audience of CHS clinicians and administrators in Beijing. As we have described before, these policies represented increased government priority on primary care and preventative services in order to address increasing health care demands in China. The CHS centers and stations serve as major foci of the new policies . Yang et al’s study indicates that the new policies are off to a good start. Certainly there is still a long way yet to go. The challenge of upgrading the clinical skills of such a large number of under-trained physicians is daunting indeed and clearly will take many years. Similarly, issues of public trust in CHS physicians, a concern that many clinicians have voiced to us during our visits, is a barrier that will need to be addressed for the CHS to fulfill its role. In many ways, medicine in China today is reminiscent of the pre-Flexner era in the U.S., with the plethora of educational standards for physicians and the absence of board certification. However, the Chinese medical establishment and government have shown that they are willing to address the issues and it will be instructive for the rest of the world to see how they do it. We hope that our medical and governmental leaders will show similar resolve in addressing problems with our health care system. 1Wang J, Kushner K, Frey JJ III, MD, Du XP, Qian N. Primary care reform in the Peoples’ Republic of China: implications for training family physicians for the world’s largest country. Fam Med. 2007;39(9):639-643. 2Kushner, K. Trust and the Family Physician. Presented at the 4th Beijing Symposium Family Medicine and Community Health Care, Beijing, China, 2006. Competing interests: None declared |
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Patrick T. Dowling, Los Angeles, California Professor/Chair Dept . of Family Medicine; UCLA School of Medicine
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This interesting study by Yang et.al. provides a glimpse of the health care demands in a country undergoing what is likely the most rapid industrialization in the history of the world. Although the country remains 62% rural, it is becoming more urbanized week by week as families engaged in small scale farming flock to the urban centers for jobs in factories manufacturing goods, once made in America, now to be shipped to America. Between 1900 and 2000 the leading causes of death in the US shifted from acute infectious to chronic non-communicable disease. The same has happened to China, but in a much narrower time frame, and they find themselves now struggling to care for a population with HTN, DM and stroke. Only 29% of the Chinese have health insurance (another reason why goods are manufactured cheaper over there), and a striking 58% of all costs are paid for out of pocket. I suspect that is similar to the payer mix in the US before the second world war. Similar to the U.S., the Chinese population is aging and the two greatest complaints about the health care system are poor access and high costs. Their physician workforce, at least in primary care, is poorly trained as 35% of the "doctors" working in the ambulatory based Community Health Sector (CHS) have high school training or less. Family Medicine residency training began in the 1990's and is still maturing. When the population was predominately rural and the leading cause of morbidity and mortality was of an acute infectious nature, a health care system based on public health -- clean water, sanitation and vaccinations supplemented with poorly trained "barefoot doctors", seemed adequate. As it now shifts to a massive urban industrial base with chronic diseases, China will need to invest heavily in a well trained physician workforce. Hopefully that will include a major emphasis on family medicine and the "medical home" model. Competing interests: None declared |
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Robert C. Bowman, MD, Mesa, AZ, USA FM Medical Educator, A T Still School of Osteopathic Medicine Arizona
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First of all, my complements to the authors who communicate better in English than I do. After decades of focus on underserved rural and urban health care needs, we seem to come no closer to solutions. This is felt most acutely at a new medical school such as ours that could graduate over 40 into the most needed career choice of family practice but will have underserved primary care outcomes cut in half by the barriers placed in their way. After reviewing China and US health system designs I am impressed in the similarity of the problem areas. 1. Both nations have citizens that are quite concerned about expensive health care to receive and inconvenient access to health care. 2. Both nations have shortages of nurses with nurses impacting health access, cost, and quality with timing before, during, and after encounters. Both nations have some understanding of the problems associated with nursing shortages, but tolerate nursing shortages. In the United States matters may be worse since nursing workforce is actively converted to nurse practitioners and physician assistants. By 2020 the United States will have about 300,000 nurse practitioners and nurse anesthetists and will be short 300,000 nurses.1 Nursing faculty moving to clinical nurse practice is a major impediment to the production of nurses. 3. Both need to figure out how to improve education for rural, lower income, and middle income populations. The US faces declines in these areas. China faces rising divisions that create inequities. These are the children that rise to serve nations where they most need service. 4. Both nations need more serving professionals on the front lines serving the populations in need of health, education, and public security - The lower and middle income people become the teachers, nurses, primary care, and public servants that provide the human infrastructure to run nations. Over 3000 lower and middle income medical school matriculants have been replaced by the highest status medical students since 1997 out of the 16,000 admitted to United States allopathic medical schools.2, 3 Osteopathic changes have also been rapid in this area.4 The medical students with the most exclusive origins and training locations are found concentrated in the most urban, highest income, medical center locations as physicians. Any less exclusive and more normal medical student has a greater probability of a health access career. Those more normal and less exclusive are failing to gain admission. They are also the most likely to choose family medicine, the specialty that dominates Community Health Center, rural, and underserved locations.5-8 5. Both nations have fewer health resources serving the populations left behind as the nations shape top concentrations of physicians, hospitals, medical schools, people, and income – China is falling behind as populations divide. The United States has already fallen behind. Over 75% of United States physicians are found in the 3300 zip codes with 75 or more physicians with 75 – 92% of specialists, 86% of graduate medical education,70% of internal medicine and pediatric primary care, and 80 – 95% of health resource distribution. It is difficult to deliver health care to the remaining 65% of the population with only 23% of physicians and with 5 - 20% of health care resources and with nurse practitioners and physician assistants leaving family practice associations and the rural, lower income, and underserved locations where they are most needed.6 Only the primary care forms remaining in the family practice mode of care in physicians, nurse practitioners, and physician assistants remain serving where most needed at 50% or greater levels rather than concentrated in zip codes with 75 or more physicians.6, 7, 9 And only family physicians remain steadily in family practice and primary care. 6. Both nations require more education and health care resources to be shifted to lower and middle income populations. Governments determine distributions of education and health resources. In the United States those who influence government decisions continue to embrace methods of distribution that fail to address education and health needs in lower and middle income populations. The most dramatic example is the United States where over 95% of those becoming physicians were born in the United States only 40 years ago. Now children born in other nations and those who have parent born in another nation take 50% of physician and engineering positions in the United States. At some point a realization of defective US distributions in child development, education, health, and other areas is required. 7. This article appears to demonstrate the same lack of understanding regarding geriatric care as articles in the United States regarding geriatric care. Geriatric care is provided by nurses, nurse practitioners, and primary care physicians locally. Together these are the backbone of adult and geriatric health care access in the nation. Geriatric physicians are a tiny fraction of geriatric care and are located in top concentrations of health resources where the populations are the youngest. Complex geriatric care, like complex primary care, cannot be provided without some form of supplementation. This is usually a medical school, medical center, donated personnel from training programs, or grant funding. Geriatric care fails in the United States for the same reasons that health access fails – failure in primary care support. Government programs, foundation funding, and the medical literature consistently miss these most important points at all phases of geriatric care. Stroke centers, heart attack centers, primary care, and health care resources are concentrated where older Americans are not.10 Older Americans and the oldest Americans must move away from the highest cost of living (health care, housing, transportation, etc.) areas to the zip code locations beyond concentrations of physicians to lower and middle income America. In the American Medical Association Masterfile database, even retired subspecialists spending their entire lives in the most concentrated physician locations can be tracked moving beyond concentrations to locations dominated by family physicians and primary care physicians that have the least health care resources.7 8. Both nations have the same problems with populations left behind facing increased out of pocket costs, increased transportation costs to receive health care, decreased health care coverage, inappropriate use of specialty care, and delays in needed health care due to design flaws. 9. Both nations apparently have the same failure of specialists to interact sufficiently with patients. In the United States specialists have increasingly hired nurses, advanced practice nurses, nurse practitioners, and physician assistants to serve in these roles. The fact remains that specialists share the least common ground with their patients. Specialists are more likely arise from exclusive origins and exclusive training. Patients have very different parents, education, and upbringing compared to physicians in America. 10. Both nations have rapidly aging populations with increasing complexities of disease and apparently little reward for caring for the most complex patients. 11. Both nations have the same problem that increased financial access to care would overwhelm insufficient primary care facility infrastructure, primary care nursing, and primary care practitioners. Pent up demand is a huge problem in China, was a huge problem in the pre- Medicare (prior to 1965) United States, was a huge problem in the pre- managed care United States, and is a huge problem today in pre-universal health care times. Primary care production and primary care retention have all improved in the United States with health policy changes involving broader eligibility, but the investments have involved many years to recover primary care production and the infrastructure of health care delivery (rural hospitals, rural clinics, primary care clinics in urban areas). 12. Both nations have failure in the most efficient, effective, reliable, and versatile health access physician specialty. China has only recently begun to establish formal family medicine. The United States re- established family medicine in 1970 but only graduates 2500 family medicine residents per year instead of the 8300 family practice graduates that it needs to restore health access sometime before the year 2050. Generic expansions of medical students or expansions of other training forms of primary care will not work. Other forms fail to adapt to various ages and populations, fail to distribute beyond concentrations, and fail the most basic test of all – remaining in primary care.6 References 1. Health Resources and Services Administration. The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered Nurses; 2004. 2. Association of American Medical Colleges. Minority Students in Medical Education: Facts and Figures XI Available at https://services.aamc.org/Publications/showfile.cfm?file=version12.pdf&prd_id=89&prvid=87 Accessed April, 2003. Washington DC 1998. 3. Association of American Medical Colleges. Minority Students in Medical Education: Facts and Figures XIII Available at https://services.aamc.org/Publications/showfile.cfm?file=version53.pdf&prd_id=133&prv_id=154&pdf_id=53, Accessed July 2006. Washington DC 2005. 4. American Osteopathic Association. Senior Medical Student Survey 2003 - 2004. 5. Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. Jama. Mar 1 2006;295(9):1042-1049. 6. Bowman RC. Measuring Primary Care: The Standard Primary Care Year. Rural and Remote Health. 2008;8. 7. Bowman RC. Physician Distribution By Concentration. Primary Care Research Methods and Statistics Conference. San Antonio, Texas; 2007. 8. Bowman RC. Logistic Regression and Rural Practice Location. In: Proceedings, Association of American Medical Colleges 2007 Workforce Conference; 2 May; Washington DC, 2007. 9. American Academy of Physician Assistants. Data and Statistics. http://www.aapa.org/research/index.html. Accessed August 26, 2008, 2008. 10. Perrotta BL, Perrotta AL. Access to state-of-the-art healthcare: a missing dynamic in consumer selection of a retirement community. J Am Osteopath Assoc. Jun 2008;108(6):297-305. Competing interests: None declared |
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