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Liang L, Liu X, Zhang L, Su Q. A novel model of ambulatory teaching of residents in general practice in China: a cross-sectional study. BMC MEDICAL EDUCATION 2024; 24:679. [PMID: 38898478 PMCID: PMC11186264 DOI: 10.1186/s12909-024-05647-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND This study aims to determine the satisfaction and future training needs of general practice residents participating in a novel model of ambulatory teaching aligned with the specifications for standardized residency training in outpatient management issued by the Chinese Medical Doctor Association (CMDA). METHODS A cross-sectional survey of the satisfaction and training needs was conducted among general practice residents at West China Hospital, Sichuan University. Patient characteristics and preceptors' feedback on the residents' performance were also analyzed. RESULTS The study involved 109 residents (30.28% men) and 161 patients (34.78% men; age: 52.63 ± 15.87 years). Residents reported an overall satisfaction score of 4.28 ± 0.62 with the ambulatory teaching program. Notably, residents scored lower in the Subjective-Objective-Assessment-Plan (SOAP) evaluation when encountering patients with the greater the number of medical problems (P < 0.001). Residents encountering patients with a shorter duration of illness (< 3 months) achieved higher scores than those with longer illness durations (≥ 3 months, P = 0.044). Residency general practitioners (GPs) were most challenged by applying appropriate and effective patient referrals (43/109; 39.45%). GPs expressed a strong desire to learn how to make decisions when facing challenging patient situations (4.51 ± 0.63). CONCLUSION This study suggests selecting patients with multiple comorbidities for ambulatory teaching and enhancing training on practical problem-solving abilities for GPs. The findings provide insights for the development of future ambulatory teaching programs.
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Affiliation(s)
- Lingbo Liang
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University,, Chengdu, 610041, China
| | - Xiangping Liu
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University,, Chengdu, 610041, China
- Department of Primary Health Care, The fourth People's hospital of Dazhu County, Dazhou, 635100, China
| | - Lin Zhang
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University,, Chengdu, 610041, China
| | - Qiaoli Su
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University,, Chengdu, 610041, China.
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Xu X, Huang J, Zhao X, Luo Y, Wang L, Ge Y, Yu X, Zhu P. Trends in the mobility of primary healthcare human resources in underdeveloped regions of western China from 2000 to 2021: Evidence from Nanning. BMC PRIMARY CARE 2024; 25:154. [PMID: 38711072 PMCID: PMC11071274 DOI: 10.1186/s12875-024-02403-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/23/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVE This research aimed to identify the fundamental and geographic characteristics of the primary healthcare personnel mobility in Nanning from 2000 to 2021 and clarify the determinants that affect their transition to non-primary healthcare institutions. METHODS Through utilizing the Primary Healthcare Personnel Database (PHPD) for 2000-2021, the study conducts descriptive statistical analysis on demographic, economic, and professional aspects of healthcare personnel mobility across healthcare reform phases. Geographic Information Systems (QGIS) were used to map mobility patterns, and R software was employed to calculate spatial autocorrelation (Moran's I). Logistic regression identified factors that influenced the transition to non-primary institutions. RESULTS Primary healthcare personnel mobility is divided into four phases: initial (2000-2008), turning point (2009-2011), rapid development (2012-2020), and decline (2021). The rapid development stage saw increased mobility with no spatial clustering in inflow and outflow. From 2016 to 2020, primary healthcare worker mobility reached its peak, in which the most significant movement occurred between township health centers and other institutions. Aside from their transition to primary medical institutions, the primary movement of grassroots health personnel predominantly directs towards secondary general hospitals, tertiary general hospitals, and secondary specialized hospitals. Since 2012, the number and mobility distance of primary healthcare workers have become noticeably larger and remained at a higher level from 2016 to 2020. The main migration of primary healthcare personnel occurred in their districts (counties). Key transition factors include gender, education, ethnicity, professional category, general practice registration, and administrative division. CONCLUSIONS This study provides evidence of the features of primary healthcare personnel mobility in the less developed western regions of China, in which Nanning was taken as a case study. It uncovers the factors that impact the flow of primary healthcare personnel to non-primary healthcare institutions. These findings are helpful to policy refinement and support the retention of primary healthcare workers.
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Affiliation(s)
- Xinyi Xu
- School of Humanities and Social Sciences, Guangxi Medical University, Nanning, China
| | - Jingyi Huang
- School of Humanities and Social Sciences, Guangxi Medical University, Nanning, China
| | - Xiaoqian Zhao
- School of Humanities and Social Sciences, Guangxi Medical University, Nanning, China
| | - Yumin Luo
- School of Humanities and Social Sciences, Guangxi Medical University, Nanning, China
| | - Linxuan Wang
- School of Humanities and Social Sciences, Guangxi Medical University, Nanning, China
| | - Yishan Ge
- School of Humanities and Social Sciences, Guangxi Medical University, Nanning, China
| | - Xingyin Yu
- School of Humanities and Social Sciences, Guangxi Medical University, Nanning, China
| | - Pinghua Zhu
- School of Humanities and Social Sciences, Guangxi Medical University, Nanning, China.
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Wei Y, Wang F, Pan Z, Wang M, Jin G, Lu X. Physical examination performed by general practitioners in 5 community health service institutions in Beijing: an observational study. BMC PRIMARY CARE 2022; 23:7. [PMID: 35172736 PMCID: PMC8759261 DOI: 10.1186/s12875-021-01619-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/22/2021] [Indexed: 11/11/2022]
Abstract
Background Physical examination is a core component of consultation. Little is known about the status quo of physical examinations performed by general practitioners in community health service institutions in China. The aim of this study was to investigate general practitioners’ performance of physical examinations in consultations. Methods An observational study was conducted in 5 community health service institutions in Beijing between November 2019 and January 2020. Eleven general practitioners were observed for one workday. Information of consecutive consultations was recorded including patient characteristics, reasons for encounter, physical examinations performed by general practitioners, length of consultation time and time spent on specific activities in consultations. Results A total of 682 consultations of 11 general practitioners were recorded. Physical examinations were performed in 126 consultations (15.8%). Physical examination was more likely to be performed in patients visiting with symptoms (P < 0.001). Majority of the 126 physical examinations were distributed in “Head, face, and neck examination” (n = 54, 42.9%) and “Cardiovascular examination” (n = 55, 43.7%). No physical examination was performed on skin, male genitalia, female breasts and genitalia, and neurological systems. Total 2823 min of activities were observed and recorded. General practitioners only spent 3.1% of the recorded time on physical examination, which was less than the time spent on taking history (18.2%), test (4.9%), diagnosis (22.7%), therapy (38.4%), and health education (8.6%). The average time spent on physical examinations was 0.8±0.4 min per consultation. Conclusion Physical examination was insufficiently performed by general practitioners in community health service institutions in Beijing. More time and commitment should be advocated for improving the quality of physical examinations in primary care. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01619-1.
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Gong X, Hou M, Guo R, Feng XL. Investigating the relationship between consultation length and quality of tele-dermatology E-consults in China: a cross-sectional standardized patient study. BMC Health Serv Res 2022; 22:1187. [PMID: 36138410 PMCID: PMC9493166 DOI: 10.1186/s12913-022-08566-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022] Open
Abstract
Background Consultation length, the time a health provider spend with the patient during a consultation, is a crucial aspect of patient-physician interaction. Prior studies that assessed the relationship between consultation length and quality of care were mainly based on offline visits. Research was lacking in E-consults settings, an emerging modality for primary health care. This study aims to examine the association between consultation length and the quality of E-consults services. Methods We defined as standardized patient script to present classic urticaria symptoms in asynchronous E-consults at tertiary public hospitals in Beijing and Hangzhou, China. We appraised consultation length using six indicators, time waiting for first response, time waiting for each response, time for consultation, total times of provider’s responses, total words of provider’s all responses, and average words of provider’s each response. We appraised E-consults services quality using five indicators building on China’s clinical guidelines (adherence to checklist; accurate diagnosis; appropriate prescription; providing lifestyle modification advice; and patient satisfaction). We performed ordinary least squares (OLS) regressions and logistic regressions to investigate the association between each indictor of consultation length and E-consults services quality. Results Providers who responded more quickly were more likely to provide lifestyle modification advice and achieve better patient satisfaction, without compromising process, diagnosis, and prescribing quality; Providers who spent more time with patients were likely to adhere to clinical checklists; Providers with more times and words of responses were significantly more likely to adhere to the clinical checklist, provide an accurate diagnosis, appropriate prescription, and lifestyle modification advice, which achieved better satisfaction rate from the patient as well. Conclusions The times and words that health providers provide in E-consult can serve as a proxy measure for quality of care. It is essential and urgent to establish rules to regulate the consultation length for Direct-to-consumer telemedicine to ensure adequate patient-provider interaction and improve service quality to promote digital health better. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08566-2.
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Affiliation(s)
- Xue Gong
- School of Public Health, Capital Medical University, Beijing, China
| | - Mengchi Hou
- China Aerospace Science & Industry Corporation 731 Hospital, Beijing, China
| | - Rui Guo
- School of Public Health, Capital Medical University, Beijing, China.
| | - Xing Lin Feng
- Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China.
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Zhong C, Huang J, Li L, Luo Z, Liang C, Zhou M, Kuang L. Development and Validation of a Rapid Assessment Version of the Assessment Survey of Primary Care in China. Front Public Health 2022; 10:852730. [PMID: 35619810 PMCID: PMC9127135 DOI: 10.3389/fpubh.2022.852730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
Background Measuring quality of primary care has attracted much attention around the world. Our team has developed and validated an Assessment Survey of Primary Care (ASPC) for evaluating quality of primary care in China. To facilitate the daily use of ASPC, this study aimed to develop and validate a rapid assessment version of ASPC (RA-ASPC) in China. Methods This is a multi-phase study on 21 experts and 1,184 patients from 12 primary care facilities in 10 cities in China. Importance, representativeness, easy understanding, and general applicability of each item in ASPC scale were rated to select the top two ranked items for constituting RA-ASPC. Reliability of RA-ASPC was tested by calculating both Cronbach's alpha and McDonald's omega coefficients. Structural validity was assessed by exploratory and confirmatory factor analysis (EFA and CFA). Concurrent validity was performed by analyzing the relationship between RA-ASPC and patient satisfaction. Discriminant validity was tested by assessing the difference of RA-ASPC scores between patients with or without family doctors. Results Ten items were selected for RA-ASPC. Both Cronbach's alpha (0.732) and McDonald's omega (0.729) suggested satisfactory internal consistency. In EFA, explained variance of RA-ASPC (72.6%) indicated its ability to measure quality of primary care in China. CFA indicators showed convincing goodness-of-fit (GFI = 0.996, AGFI = 0.992, CFI = 1.000, NFI = 0.980, RMR = 0.022, and the RMSEA = 0.000) for RA-ASPC. Positive association between RA-ASPC and patient satisfaction supported the concurrent validity of RA-ASPC. Patients with family doctors perceived higher quality of primary care than those without family doctors, indicating good discriminant validity of RA-ASPC. Conclusion The theoretical framework of RA-ASPC was in line with internationally recognized core functions of primary care. Good psychometric properties of RA-ASPC proved its appropriateness in assessing quality of primary care from patients' perspectives in China.
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Affiliation(s)
- Chenwen Zhong
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Junjie Huang
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Lina Li
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
- Bureau of Veteran Cadres of the Huadu District Party Committee, Guangdong, China
| | - Zhuojun Luo
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Cuiying Liang
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Mengping Zhou
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Li Kuang
- Department of Health Policy and Management, School of Public Health, Sun Yat-sen University, Guangzhou, China
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Wei Y, Wang F, Pan Z, Jin G, Wang D, Lu X, Cao Q. Work Content of General Practitioners in Beijing, China: A Multi-method Study. Front Public Health 2022; 10:870224. [PMID: 35570960 PMCID: PMC9096235 DOI: 10.3389/fpubh.2022.870224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Despite the dramatic growth of primary care in China, little evidence showed what general practitioner (GP) do and how GP provided medical service in Beijing. Objective This study aimed to explore the work content of GPs in primary care in Beijing. Methods A multi-method study was conducted in five community health service institutions using non-participant observation and critical incident technique interview. Eleven GPs was recruited by purpose sampling, with each GP recording details of 100 patient encounters. Health problems of patients and activities of GPs were observed in consultations. Then, critical incident technique interviews were conducted focusing on GPs' works out of clinics and challenge. Results A total of 1, 100 patients encounters and 1,897 reasons for encounter (RFEs) were recorded from 11 GPs. There were 1897 RFEs (1.72 per encounter) and 2,762 health problems (2.51 per encounter) from 1,100 encounters during our observation. GPs' work related to consultation was focus on disease diagnoses and treatment. Physical examination and investigations were performed in only 15.5 and 17.1% consultations, respectively. Procedures for chronic disease management were infrequently provided to patients (0.4–26.6%). Time spent in each work process in consultations ranged from 0.68 ± 0.27 min for reservation to 4.00 ± 2.45 min for surgical treatment. In addition to clinical work, there were tasks about health files, contracted family doctor services, health education, teaching students, and scientific research. Conclusion This study illustrated the complexity of GPs' work and heavy workload in Beijing, China. More attention and effort are needed to develop GPs performance and release GPs' work workload in primary care.
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Affiliation(s)
- Yun Wei
- Department of General Practice, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Feiyue Wang
- Department of General Practice, School of General Practice and Continuing Education, Capital Medical University, Beijing, China
| | - Zhaolu Pan
- Department of General Practice, School of General Practice and Continuing Education, Capital Medical University, Beijing, China
| | - Guanghui Jin
- Department of General Practice, School of General Practice and Continuing Education, Capital Medical University, Beijing, China
| | - Dawei Wang
- Department of General Practice, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Xiaoqin Lu
- Department of General Practice, School of General Practice and Continuing Education, Capital Medical University, Beijing, China
| | - Qiumei Cao
- Department of General Practice, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- *Correspondence: Qiumei Cao
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Haines S, Savic M, Nielsen S, Carter A. Key considerations for the implementation of clinically focused Prescription Drug Monitoring Programs to avoid unintended consequences. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 101:103549. [PMID: 34920217 DOI: 10.1016/j.drugpo.2021.103549] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 11/18/2021] [Accepted: 11/22/2021] [Indexed: 11/28/2022]
Abstract
Prescription Drug Monitoring Programs (PDMP) are electronic databases that are used to track and monitor the prescribing and dispensing of controlled substances, including opioid analgesics and benzodiazepines. PDMP have been widely implemented throughout North America and are currently being introduced in Australia and some parts of Europe. PDMP were originally developed by and for law enforcement, however many jurisdictions have now shifted use toward clinical care and harm reduction through early identification of prescription dependence and extra-medical use, and to ensure appropriate supply of controlled substances to the community through monitoring health care provider prescribing and dispensing patterns (Deloitte, 2018; Picco et al., 2021a; CDC, 2021a, U.S Department of Justice, 2018). Clinically-motivated PDMP highlight medication-related risk, based on the patient's prescribing and dispensing history. Health care professionals can use this information to aid or inform clinical decision-making and provide opportunities for intervention and treatment (Deloitte, 2018) . However, a number of harms have been associated with the use of PDMP, including increased stigma and discrimination, untreated pain and mental illness, and denial of appropriate health care for those identified as 'high risk'. In this article we examine these harms and potential mitigating factors. We conclude with some suggestions and future directions for research to address some of the current uncertainties regarding PDMP use. We highlight the need for mixed methods research to better understand the personal impacts of PDMP policy on the populations they were designed to aid.
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Affiliation(s)
- Sarah Haines
- Turner Institute for Brain and Mental Health, Monash University 18 Innovation Walk, Clayton VIC 3800, Australia.
| | - Michael Savic
- Turning Point Research Centre, Eastern Health, 110 Church Street, Richmond, 3121, Australia; Monash Addiction Research Centre, Monash University, Level 3, Building G Moorooduc Hwy, Frankston VIC 3199, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Level 3, Building G Moorooduc Hwy, Frankston VIC 3199, Australia
| | - Adrian Carter
- Turner Institute for Brain and Mental Health, Monash University 18 Innovation Walk, Clayton VIC 3800, Australia
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Association between doctor-patient familiarity and patient-centred care during general practitioner's consultations: a direct observational study in Chinese primary care practice. BMC FAMILY PRACTICE 2021; 22:107. [PMID: 34049489 PMCID: PMC8161971 DOI: 10.1186/s12875-021-01446-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 04/26/2021] [Indexed: 12/30/2022]
Abstract
Background Patient-centred care is a core attribute of primary care. Not much is known about the relationship between patient-centred care and doctor-patient familiarity. This study aimed to explore the association between general practitioner (GP) perceived doctor-patient familiarity and the provision of patient-centred care during GP consultations. Methods This is a direct observational study conducted in eight community health centres in China. Level of familiarity was rated by GPs using a dichotomized variable (Yes/No). The provision of patient-centred care during GP consultations was measured by coding audiotapes using a modified Davis Observation Code (DOC) interactional instrument. Eight individual codes in the modified DOC were selected for measuring the provision of patient-centred care, including ‘family information’, ‘treatment effects’, ‘nutrition guidance’, ‘exercise guidance’, ‘health knowledge’, ‘patient question’, ‘chatting’, and ‘counseling’. Multivariate analyses of covariance were adopted to evaluate the association between GP perceived doctor-patient familiarity and patient-centred care. Results A total of 445 audiotaped consultations were collected, with 243 in the familiar group and 202 in the unfamiliar group. No significant difference was detected in overall patient-centred care between the two groups. For components of patient-centred care, the number of intervals (1.36 vs 0.88, p = 0.026) and time length (7.26 vs. 4.40 s, p = 0.030) that GPs spent in ‘health knowledge’, as well as time length (13.0 vs. 8.34 s, p = 0.019) spent in ‘patient question’ were significantly higher in unfamiliar group. The percentage of ‘chatting’ (11.9% vs. 7.34%, p = 0.012) was significantly higher in the familiar group. Conclusions This study suggested that GP perceived doctor-patient familiarity may not be associated with GPs’ provision of patient-centred care during consultations in the context of China. Not unexpectedly, patients would show more health knowledge and ask more questions when GPs were not familiar with them. Further research is needed to confirm and expand on these findings.
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Zhang C, Fang F, Peng M, Zhao Y, Liu R, Jia C. Qualitative evaluation of the general practitioner chronic non-communicable diseases training programme. BMC MEDICAL EDUCATION 2020; 20:297. [PMID: 32912234 PMCID: PMC7488002 DOI: 10.1186/s12909-020-02226-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/03/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND In China, general practitioners have limited ability to provide care for common chronic non-communicable diseases because they lack postgraduate training. In an attempt to improve general practitioners' skills in this regard, the present authors previously launched the Chronic Non-Communicable Diseases Training Programme. The present study aims to evaluate the effectiveness of this programme. METHODS Thirty-nine trainee general practitioners who participated in the programme underwent semi-structured interviews, which explored how they performed the training, what they achieved from the programme, and their suggestions for future programmes. The interview data were analysed using a thematic analysis approach. RESULTS Under the guidance of supervisors, the thirty-nine trainee general practitioners completed the structured but individualised training plan, which comprised a four-day basic theory class, 3 months practising in a ward, and 6 months assisting in an outpatient clinic. They reported an improvement in their ability to provide care for chronic non-communicable diseases and perform two-way referral, as well as their communication with patients. They also reported that, since returning to their communities, they had become more confident, were building better relationships with their patients, and had changed their clinic behaviours from copying prescriptions to making medical decisions independently. Their principal suggestion for the training programme was to alter the order of the training, as they preferred to practice in the ward before assisting in the outpatient clinic. CONCLUSION The course comprised a learner-centred, practice- and apprenticeship-based, general-practitioner training programme. Given the participants' progress and the beneficial effects of the programme reported in the interview data, it appears to be worthwhile to extend the General Practitioner Chronic Non-Communicable Diseases Training Programme.
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Affiliation(s)
- Chunyu Zhang
- Department of Health Reform and Development, China-Japan Friendship Hospital, Yinghua East Road 2#, Chaoyang District, Beijing, 100029, P.R. China
| | - Fang Fang
- Department of Health Reform and Development, China-Japan Friendship Hospital, Yinghua East Road 2#, Chaoyang District, Beijing, 100029, P.R. China
| | - Mingqiang Peng
- Hospital Office, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Ying Zhao
- School of Management, Beijing University of Chinese Medicine, Beijing, P.R. China
| | - Ruixue Liu
- School of Management, Beijing University of Chinese Medicine, Beijing, P.R. China
| | - Cunbo Jia
- Department of Health Reform and Development, China-Japan Friendship Hospital, Yinghua East Road 2#, Chaoyang District, Beijing, 100029, P.R. China.
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