Analysis of the History and Current Situation of the Development of General Practice Teaching Clinics in China ()
1. Introduction
With the deepening of medical reform, China has gradually emphasized the development of general medicine since 2010, and many institutions of higher education have begun to set up the specialty of general medicine [1] . However, the development of general medicine in China is relatively late, the number of general practitioners is less than the number of clinical specialists, and compared with foreign countries, there is an even greater lack of physicians serving the grassroots level in China, according to statistics, in 2018, China obtained a certificate of eligibility for general practitioner training of about 150,000 people, and there are about 300,000 existing general practitioners, with an average of 2.22 general practitioners for every 10,000 people, and in the United Kingdom, more than 90% of the primary care services are provided by the GP clinics provided by general practices, with an average of about 1600 people served by each general practitioner [2] . To promote the development of primary care in China, there is still a need to train more general practitioners, and it is essential to explore effective training methods. A general practice teaching clinic is an independent clinic that can provide teaching functions, emphasizing the trainee as the main body, directly facing the outpatients under the informed consent of the patients, who need to do the history taking, physical examination, and diagnosis, and draw up the further examination and treatment plan, with the supervising physician observing, monitoring, and guiding the whole process, and providing feedback at the end of the consultation, so as to provide the trainees with a more complete learning process and ensure the quality of the learning. The quality of the learning process can be ensured by [3] . With the successive introduction of the construction system related to general practitioners, general practitioners have gradually become the main providers of primary health care services, and the training of excellent general practitioners has become the most important task of primary health care [4] . The establishment of general practice teaching outpatient clinics is particularly important, and general practice teaching outpatient clinics have more patients with undifferentiated diseases and multiple coexisting diseases, which is of great help to the improvement of the receiving ability of general practice training students. The following is the current development of general practice teaching clinics in China.
2. Current Status of Development of Teaching Clinics
At present, China’s teaching clinic is divided into three kinds, the first is “observation clinic”, most students do not have clinical experience, follow the senior physician in the clinic to receive the process of learning knowledge, students do not participate in it, resulting in the enthusiasm and enthusiasm of the students is not high, and learning knowledge is relatively small. The second type is “assistant clinic”, where students follow the teaching teacher’s outpatient clinic to help the teacher to give medical advice, prescriptions and simple consultations and help to maintain the order of the clinic, students participate in it, but the clinical diagnosis and treatment is still the teaching teacher to decide, the students cannot cultivate clinical thinking, idle thinking. The third type is called “Supervised Clinic”, in which students are mainly involved in the whole process of consultation, physical examination, preliminary diagnosis and initial treatment, but due to the narrower knowledge of students, they still need to report their conditions to the teaching teacher for further treatment, but this method enables students to be involved in the whole process of receiving patients, and improves the motivation of students in learning, which can improve students’ clinical reception skills. It can improve students’ clinical diagnosis ability, and this kind of clinic teaching method is student-centered, which is a real teaching clinic [5] .
3. Exploration of Our General Practice Teaching Outpatient Teaching Model
With the development of teaching clinics, general practice has also begun to explore corresponding teaching methods, and major hospitals in China have explored a variety of teaching methods in order to improve the reception ability of general practice students. The “three-step feedback method” was first proposed by Cai Peifen et al. in 2022, in which the resident trainees receive and evaluate themselves, analyze the deficiencies and omissions in the process of receiving, and then the instructor analyzes the trainee’s questioning, physical examination, initial diagnosis and initial treatment, and proposes the points that deserve affirmation and the points that need improvement. After that, the instructor analyzed the trainee’s questioning, physical examination, initial diagnosis and initial treatment, and suggested the positive points and the points that need to be improved. The “three-step feedback method” enables students to remember the theoretical knowledge and improves their motivation, self-confidence and diagnostic ability by reviewing the diagnostic process three times, but due to the large number of undifferentiated diseases in general outpatient clinics, this diagnostic method takes a long time [6] . By recommending its optimization, we can solve the problem that the duration of the “three-step feedback method” is too long, focusing on reducing time costs, improving efficiency, and better adapting to the conditions of hospital outpatient clinics. The “role-playing, scenario simulation method” was developed by Hongshuang Jiang in 2022, it was first applied to the general practice teaching clinic. The model mainly consists of a script written by the teacher, and the student plays the role of a doctor to ask the “patient” about the medical condition, physical examination, diagnosis and treatment, and the patient plays the role of a doctor by following the principle of “no questions, no answers” and setting up obstacles during the process of taking the history, and setting up obstacles during the process of taking the history. The patient actor follows the principle of “no questions, no answers” and sets up obstacles in the process of history-taking. After the role-playing and scenario simulation, feedback is given on the process of history-taking, the instructor evaluates the process, and the trainee writes a reflective SOAP case and analyzes the gains and shortcomings. Although role-playing and scenario simulation can fully mobilize students’ enthusiasm in general practice teaching clinics, and make the training students more actively participate in it than the traditional teaching method, due to the fact that the patients in this mode are played by doctors, it lacks authenticity and it is difficult to take care of the patients’ psychological problems due to diseases, which is not in line with the development of “biomedicine-psychology” model of general practice. It is not in line with the development of “biomedical-psychological” model of general practice [7] , and it is recommended to improve the authenticity of “role-playing and scenario simulation” methods, so that students can better participate in the psychological problems of patients during the simulation process. The diversified teaching model, which was first explored and used by Ma Junzhuang et al. at the First Hospital of Zhejiang University, is divided into case-based learning (CBL), problem-based learning (PBL), resource-based learning (RBL) and case-based learning (CBL), and the teaching model is divided into case-based learning (CBL), problem-based learning (PBL), and resource-based learning (RBL). In the three aspects of case-based learning (CBL), problem-based learning (PBL), and resource-based learning (RBL), ZJI General Practice Base has constructed a diversified teaching mode based on “PBL + CBL” and supplemented by RBL, which changes the learning mode from passive transmission to active acceptance by the students and improves the students’ self-learning ability, which is in line with the characteristics and novelty of clinical teaching. This model is in line with the characteristics of clinical teaching, is relatively new, enables students to actively participate in it, and updates the teaching model of general practice clinics [8] . It is recommended that the practical experience of diversifying teaching modes should be accumulated to encourage the identification of the advantages of various methods and the formation of a more systematic and comprehensive teaching mode of general medicine.
4. Problems in the Development of General Practice Teaching Clinics
4.1. Weak Faculty and Lack of Uniform Standards for Teaching [9] [10] [11]
4.1.1. Inadequate Inclusion Criteria for Teachers
In China, in order to reflect the importance of general practice teachers, the bases often recommend highly educated physicians with high titles as the qualifications for general practice teachers, and the inclusion criteria for general practice teachers only have specific requirements for the academic qualifications and work experience of the teachers, ignoring the teaching attitude and enthusiasm of the teachers, which results in the fact that the physicians with high academic qualifications do not necessarily have the energy and enthusiasm to participate in the work of general practice teaching, while the physicians with enthusiasm and enthusiasm cannot play a good role in the work of general practice teaching. As a result, physicians with high education may not necessarily have the energy and enthusiasm to participate in general practice teaching, and physicians with enthusiasm and energy cannot play a good role in general practice teaching. Good teachers can establish good interpersonal relationships with students and encourage them to actively participate in the teaching process. There is a need to standardize the criteria for faculty inclusion, and advanced degrees and seniority should not be the only criteria for inclusion. The issue of faculty recruitment criteria is addressed by recommending more comprehensive criteria that not only take into account academic qualifications and work experience, but also focus on attitude and enthusiasm for teaching. Ensure that physicians of high academic caliber have the passion and ability to mentor students.
4.1.2. Lack of Teacher Training Institutions
Although China has approved some teacher training institutions for general practitioners, the number is far from enough to meet the demand for general practitioner teachers, and many institutions lack unified training standards, and some of them train for only 1 - 2 days, so the quality of training cannot be guaranteed at all; most hospitals do not carry out the assessment of teaching ability for general practitioner teachers, and most of the teachers still teach in a traditional and personal experience-based way. Most hospitals do not assess the teaching ability of general practice teachers, and most of them still teach in a traditional, personal experience-based way, lacking unified teaching standards. To address the problem of insufficient teacher training institutions, it is recommended that the number of such institutions be increased and that uniform training standards be developed to ensure the quality and depth of training. This will enable teachers to better adapt to the teaching requirements of general medicine.
4.1.3. Lack of Textbooks for Teacher Training in General Practice
Although China published “Guidelines for Teaching Teacher Training in General Practice” in 2013, the book has not been popularized in China, and the lack of a unified standard for teacher training in China has led to the fact that the qualifications of the general practice band teachers are only based on their personal experience in imparting their knowledge, and the students are receiving varying levels of knowledge. Tackle the problem of inadequate textbooks by advocating for the wider use of existing materials like the “Guidelines for Teacher Training in General Practice”. Simultaneously, establish more uniform training standards to ensure consistency in the knowledge levels received by students nationwide.
4.2. Impact of Tight Teaching Schedule, Poorly Configured Teaching Clinics, and Patient Wishes
4.2.1. Teaching Time Is Urgent
Due to the number of outpatient visits, although China has been promoting the hierarchical diagnosis and treatment for many years, the results have been very few, large tertiary hospitals, the daily volume of 10,000 patients, students have limited contact with patients time, cannot achieve the effect of training and learning, the teaching clinic needs to be more effective in teaching, the establishment of a specialized general practice teaching clinic, to cultivate the students’ ability to receive the diagnosis.
4.2.2. Poor Configuration of the Teaching Clinic [12]
The teaching clinic should be equipped with a general practice consultation room and a teaching observation room. The general practice consultation room should be no less than 15 m2, equipped with consultation beds, wall-mounted sphygmomanometers, thermometers, funduscopes, otoscopes, sunshades, hand-washing sinks, and audio capture equipment. A letter to patients is posted at the entrance to facilitate patients’ understanding of the functions and modes of the general practice teaching clinic, and patients should sign an informed consent form if audio or video recording is required during the consultation. The teaching observation room is not less than 10 m2, equipped with one-way observation glass, a computer connected to a sound processor and video equipment that can play a large screen. The configuration of the general practice teaching clinic is insufficient in all bases, and the decrease in the number of cases received, the maintenance and renewal of the equipment are all invisible consumption, and the pressure on the funds is large, which has led to the lack of attention paid by all the bases to the establishment of the general practice teaching clinic, and the students of the training program are still rotated in the wards, and the number of critically and severely ill patients is high due to the fact that there are more patients in the wards. Address issues related to clinic configuration by advising each base to adequately equip general practice teaching clinics with necessary facilities and spaces. This ensures the effectiveness and educational impact of the clinics.
4.2.3. Poor Patient Acceptance [13] [14] [15]
The majority of general practice visits are for early undifferentiated disease, and according to a study by Miraj Shah-Khan M. D. et al., almost all patients (97%) agreed that it was important for students to learn by observing their physicians at work. 75% of patients felt that it was appropriate for the attending surgeon to teach during the office visit, whereas 69% felt that it was appropriate for the physician to ask questions of the student. The majority of patients felt that it was acceptable for the student to be interviewed by a physician who was present at the office visit, as opposed to an individual physician. Patients were more likely to find it acceptable for a student to have an interview with a physician present than to have an interview alone (25% vs. 69%). The same was true for physical exams. 62% of patients found it acceptable to have the student perform the physical exam when the physician was in the room, and only 23% found it acceptable for the student to perform the exam alone. Gynecological diseases and colorectal surgical diseases that require exposure of the patient’s private parts, patients preferred the presence of the attending physician to the presence of the medical student, and the general practice teaching clinic needed to communicate with the patients themselves in the hope that the patients would understand and accept that the students in training would receive the patients alone, and that the early undifferentiated diseases would be seen in the general practice clinic, but the lower acceptance of patients with gynecological diseases and colorectal surgical diseases reduced the number of diseases, which was also a general practice Provide recommendations for improving patient acceptance by suggesting that clinics adopt a more flexible approach in communication with patients. Emphasize the importance of respecting patients’ preferences to enhance their acceptance of students’ involvement in consultations.
5. Implications for the Development of General Practice Teaching Clinics
5.1. General Practice Teaching Clinics Can Improve Students’ Initiative and Motivation to Attend [16] [17] [18]
The traditional way of teaching is observation-type teaching and assistant-type teaching, and the teaching teacher intersperses the explanation to the students in the process of receiving patients. Due to the fact that the general outpatient clinic is dominated by patients with early stage of undifferentiated diseases and multidisease coexisting patients and the daily outpatient volume of the tertiary hospitals is large, for the sake of the efficiency of seeing the patients, the teachers are often unable to pay attention to the students, and the students do not have high motivation in learning, and they cannot participate in the process of diagnosis and treatment, and the opening of the general practice teaching clinic With the opening of general practice teaching clinic, students are required to participate and think about the whole process from receiving patients, asking medical history, physical examination, preliminary diagnosis and treatment. Through the guidance of the instructor on the deficiencies, students can have a deeper understanding of the process of receiving patients, so that they can actively participate in the process of receiving patients, and improve the initiative and enthusiasm of the students.
5.2. General Practice Teaching Clinics Can Develop Students’ Doctor-Patient Communication Skills [19]
Doctor-patient relationship often occurs and develops in medical practice activities, it is a special kind of medical interpersonal relationship that needs to be based on technical work, morality as the core, and law as the criterion. According to Wu Guijie’s research, doctor-patient disputes due to technical problems caused by less than 20% of doctor-patient conflicts, but because of the doctor’s service attitude, speech style, and medical ethics caused by doctor-patient conflicts as high as 80%, although in many colleges and universities have opened a course on doctor-patient communication, but due to the lack of practical experience, as well as the personalized characteristics of modern adolescents, doctor-patient communication is still a major problem in the clinical field. In the outpatient clinic, patients are often emotionally unstable because of queuing, queue-jumping, wrong number, and wrong test order. With the opening of the general practice teaching clinic, students are the main body of the clinic, which achieves mutual benefit and win-win situation for the medical side and the patient side through the dual care of the patient’s body and mind.
5.3. General Practice Teaching Clinics Are an Important Part of the Training of Qualified General Practitioners
The role of the teaching clinic in clinical teaching was fully affirmed by foreign educators in the 19th century [20] , general medicine is a clinical secondary discipline for individuals, families and communities, integrating clinical medicine, preventive medicine, rehabilitation medicine, as well as medical psychology, humanities and social sciences in one of the comprehensive medical specialty disciplines. General practitioners rotate through internal medicine, surgery, obstetrics and gynecology, pediatrics, psychiatry, and other departments, usually focusing on diseases and giving corresponding treatments for a certain disease, which is not in line with the “patient-centeredness” of general medicine, which focuses on the individual and provides humanized and individualized services with the goal of health. Moreover, general medicine is based on the biopsychosocial medical model. The opening of the general practice teaching clinic is a move from “theory” to “practice”, where the duties of the general practitioner are experienced throughout the entire consultation process, regardless of gender, age, physical or mental illness and social problems, and can provide a continuum of services to individuals and families with their own unique attitudes and skills. Through participating in the whole process of consultation and treatment, students can improve their competence in medical work, improve their communication skills between doctors and patients, cultivate their concepts and thinking of general practitioners, and provide better channels for cultivating more excellent general practitioners.
6. Conclusion
General practice teaching outpatient clinics in China are relatively late in the development, the current development is relatively slow, general practice teaching outpatient teaching mode is also in the exploratory stage, a variety of teaching modes can enhance the ability of the training students to receive the diagnosis, but due to the large number of outpatient clinic days, it is still necessary to explore a more standardized mode of teaching to improve the quality of teaching and can bring the patient a good experience of the clinic to reduce the contradiction between the doctor and the patient, the teachers of our country to incorporate the standard is not perfect, lack of teachers and fewer standardized training institutions make the knowledge received by general practitioners across the country unbalanced, and lack of uniform standards for qualified teacher training, which is a problem that needs to be solved urgently. The general practice teaching clinic is important for the clinical communication ability of general practitioners and the enthusiasm and initiative of general practice training trainees to participate in the diagnostic and treatment process, and it is important for the cultivation of an excellent general practitioner, which can promote the development of general practice, and China should pay more attention to the development of the general practice teaching clinic.