Characteristics and Workload of Pediatricians in China

Pediatrician Training and Retention Strategies

The PPTC number in China (0.40) was half that in Japan (0.93)¹³ and a quarter that in the United States (1.9),¹⁴ thus lagging greatly behind the average level of developed countries. Each Chinese pediatrician takes care of 10 times more patients than an American pediatrician, clearly indicating the severe shortage of pediatricians in China. The maldistribution and shortage of physicians poses a challenge to the health systems of many countries.^15–19

The Chinese government’s goal is to increase the ratio to 0.69 by 2020, necessitating a net increase of 90 000 pediatricians. Many measures have been taken to train new pediatricians. Because the maldistribution of pediatricians is generally combined with socioeconomic disparities,²⁰ these measures may not prevent trained pediatricians from moving to urban areas, and rural areas that need pediatricians the most may continue to benefit little. This is borne out by evidence from other countries; in Japan in 2004, for example, a new postgraduate medical education program was introduced to improve residency training and optimize distribution, but the distribution worsened.^13,17

The experience of the African Pediatric Fellowship Program has provided a powerful example of how to deal with retention. Approximately 98% of trainees from local hospitals finished the program in an advanced institution and returned to their hometowns to build practice, training, research, and advocacy.¹⁹ Our hospital in Shanghai has been training pediatricians from western provinces of China since 2012. After the training, trainees return to their local hospitals to assume important roles. Unfortunately, the current targeted training programs are far too small and too few to meet the vast needs of the whole country, partly because there are no financial incentive or reimbursement mechanisms for trainees.

Because China is extremely diverse, a one-size-fits-all approach is inappropriate. Based on the high dropout rate in primary hospitals, a targeted location-allocation strategy may be an effective option when recruiting new pediatricians to minimize access inequality and balance supply and demand in the long run.²⁰ However, working in rural and remote areas is not appealing to most pediatricians and, in the short-term, active deployment of existing human resources may be another route to address the challenge. In the United States, for example, the problem of dropout rates was reduced by providing part-time positions targeted at female pediatricians who wanted to balance their personal and professional lives,²¹ and family doctors are also encouraged to take care of children.

Structural Reform of the Pediatric Care System

When the spread of “medical dispute profiteers” attracted academic and industrial attention in China, the situations in other countries with a similar number of pediatricians were found to be more harmonious between pediatricians and patients’ families. More interestingly, the media coverage on the crisis of the pediatrician shortage in China came from those provinces where pediatrician resources are more abundant. In these regions, more than half of the pediatric workload is concentrated in tertiary hospitals, leading to the perception of a shortage of pediatricians. This is exacerbated by the combination of low fertility and increasing wealth, which has led to increasing demands for high-quality pediatric care.²² The ever-expanding tertiary facilities in pediatric care remain insufficient to meet the increasing demand for better care nationwide. Therefore, the key strategy is to return to the 3-tiered medical referral system with a gatekeeping system like that in the United Kingdom. Unfortunately, many primary care facilities and personnel in pediatric services are broken because of negligence over the past decade, and the availability of secondary pediatric care has shrunk severely.²³ Because the pediatric workload increased in the last decade when children’s numbers remained stable in China, we can foresee that, without gatekeeping, the workload in tertiary hospitals will continue to grow. To rebuild this system, the Shanghai government divided the metropolis with nearly 25 million residents into 5 clusters and is attempting to link up tertiary, secondary, and primary pediatric care facilities to regionalize child health care and optimize the utility of high-level resources. Health maintenance and simple health problems are dealt with at the local level, and more complicated cases are treated at the tertiary level. Physicians at higher-level hospitals take turns to provide services and training in lower-level clinics to boost quality of care. Family doctors are also encouraged to take care of children.²⁴ These approaches are potentially applicable to a larger network across the urban-rural boundary.

Additionally, there is a special system, MCH, covering almost the entire country. MCH is both an administrative and a health care system providing health maintenance and basic health care.^25,26 However, the causes of death and disease spectrum have also changed over the years. Infection has given way to preterm birth or low birth weight as the leading cause of death. The rapid increase in childhood asthma²⁷ and other allergic disorders, attention-deficit/hyperactivity disorders,²⁸ obesity,²⁹ and precocious puberty³⁰ requires new knowledge and therapies that are often foreign even to well-trained physicians. The health care model must change accordingly from a pure medical to a biopsychosocial model. However, most Chinese pediatricians are not yet prepared for this. In Switzerland and the United States, family doctors take care of ∼20% of the child workload.^31,32 Thus, training traditional MCH physicians as qualified pediatricians represents both an opportunity and a challenge.

Furthermore, the physician fee structure must also match the strategy of regionalizing and optimizing the limited resources. In China, there is no referral system among primary, secondary, and tertiary hospitals. Although most of the population is covered by government health insurance, most patients pay a portion of medical costs out of pocket, particularly in outpatient departments and even in public hospitals, and have the right to choose their own provider. Of greater concern are the negligible differences in the already low physician fees between hospital levels. This, coupled with the 1-child family policy, has encouraged families to seek the best care within their reach even for trivial problems. With economic development and transportation convenience, the demand for high-level pediatric care is ever increasing. Many parents choose to attend a tertiary center, which is considered to provide the best care at a low price similar to that of lower-level hospitals. Furthermore, pediatricians’ job satisfaction is disappointingly low because of their low payment relative to other specialties, high workload, and intense patient-physician relationship.³³ Consequently, few medical students want to become pediatricians and 12.6% of practicing clinicians are giving up their professions and moving to other careers. The large income gap between pediatricians and other specialists also must be addressed by both market force and government policies.

Finally, technologies such as electronic medical records, telemedicine, connected interactive medicine networks, and even artificial intelligence may, to some degree, resolve the challenge of insufficient and uneven distribution of pediatric resources and facilitate training.

Limitations

First, although the R was high (91.7%), a systematic response bias is possible. However, hospitals that did not respond were scattered across the country and across levels, which suggests this is not the case. Second, we did not consider migrant workers. No data were available to estimate accurate numbers of the migrant population at the county level. Because migrants generally move from rural to urban areas or from less developed to more developed regions, the PPTC number in western regions may have been overestimated. However, only a minority of migrants are accompanied by children, most of whom are left behind with relatives,¹⁴ so the number of migrant children is relatively small and unlikely to have influenced the analysis.