Global Perspectives: China
Xuejun Zeng, MD, PhD, FACP
Peking Union Medical College Hospital (PUMCH)
Chief, Division of General Internal Medicine
Chief, Department of General Practice
China, officially the People’s Republic of China, is a unitary sovereign state in East Asia and is the world’s more populous country. The country is governed by the Communist Party of China, and its capital is Beijing. *
*Source - Wikipedia
What inspired you to become a physician?
I wanted to be a doctor since I was a child when I would act as a doctor while playing. My brother said he never doubted that one day I would become a doctor. It seemed to me, from my interaction with doctors working in communities, that doctors possess magic, because they could diagnose diseases from such subtle symptoms and they had the power to heal. Doctors are well respected by people around them, because they are always willing to help. I admired them so much and wanted to become one of them.
I graduated from Hunan (Xiangya) Medical School. I then had the great honor to be a sub-intern at the prestigious Peking Union Medical College Hospital (PUMCH), which was founded by the Rockefeller Foundation in the early twentieth century. My enthusiasm in patient-care grew even stronger through my internal medicine residency at PUMCH. It was clear to me that my goal in life would be the pursuit of excellence in medicine.
I love to investigate and solve problems systemically. Medicine is an art, and it gives me perfect opportunities to combine my curiosity with action. As a physician, I am able to know people, their diseases, and their stories. It is such a great experience of personal growth and I enjoy it every day.
Describe your position at Peking Union Medical College Hospital PUMCH.
I am a senior Rheumatologist and Professor of Medicine. In 2002, I was selected by PUMCH, with funding from the China Medical Board, to learn the Development of General Internal Medicine, Primary Care and Residency program at the University of California-San Francisco (UCSF). In 2004, the first academic division of General Internal Medicine was founded at PUMCH, which was the first in China. I served as Division Chief, as well as Vice Chair of the Department of Medicine from 2007-2014, responsible for medical education and residency training. We incorporated the concept of primary care in the training, and piloted training in ambulatory care settings. Recently, I was appointed the chairperson of the Department of General Practice, which promotes the concept of caring for a person as a human being, not as diseases with symptoms and signs.
What do you enjoy about being an internist?
Vision decides direction. As an internist, your core duty is taking care of people, not just diseases; therefore the aim of health care in medicine fits better than in any other subspecialties. Dr. Xiaoqian Zhang, a prominent chairperson of Department of Medicine in PUMCH, always emphasized that doctors must treat their patients carefully in clinical practice as if they are standing by a cliff, or treading on thin ice. An internist must have broad knowledge and skills in medicine, psychology, preventative medicine, and a variety of other subjects, to effectively provide the best care to patients. Doctors need to work together to transform the current disease-centered care model to human-centered care model in China. I am confident that we can build an efficient system to train the next-generation of internists and general practitioners in China.
I enjoy the internist’s approach to patient care by addressing patients’ problems through close clinical observation and rigorous clinical reasoning, just as I enjoy passing the knowledge and professionalism to the next generation through bedside teaching.
What is the role of the internist in China? What are the education and training requirements needed to practice internal medicine or one of the subspecialties of internal medicine?
Today, China is in great need of a large number of well-trained internists. China has a long history of internist-based health care. Since the establishment of the People’s Republic of China in 1949, village doctors, the first generation of internists providing primary care to millions of Chinese people in rural areas, contributed to the improvement of health care, although most of them did not have a college-level medical education. They significantly lowered the newborn mortality and achieved good disease control with very limited resources. Today, the primary care facilities in villages, the township health care centers and the county hospitals, constitute the three-tier health care system in rural China.
In urban areas, health care institutions are organized into three tiers, namely primary, secondary, and tertiary. A primary facility is typically a community health care center that contains less than 100 beds. Their tasks are to provide preventive care, basic patient care and rehabilitation. Secondary are usually hospitals with more than 100 beds, but less than 500, to provide comprehensive health care services, as well as medical education and research at a regional level. Tertiary are general hospitals with a bed capacity exceeding 500 in the city, to provide specialized health care services and play a greater role in medical education and research. They serve as medical centers at either the provincial or national level.
At the same time, medical education is transitioning to train elite health professionals based on this three-tier hospital system in urban China. Most physicians graduate from medical school with a Bachelor of Medicine degree after completing at least five years of study. On many occasions, they would pursue an additional 3-6 years of graduate studies to get a higher degree. After graduation, medical students would begin their career in a hospital through application and selection. In the past three years, it is required that all medical graduates have 3 years of residency training in a tertiary care hospital to be qualified to practice. They have to pass the national physician qualification examination before or during their residency. After 3-5 years of training in internal medicine, these physicians will choose to become an internist or a subspecialist. Most of them would take another 3-5 years of subspecialty training before they obtain an attending position. Medical residency is critical, as it facilitates the long-term development of the specialties of internal medicine, the professional training of doctors, and distribution of human resources within China’s tiered health care delivery system.
Generally speaking, young physicians in tertiary hospitals learn quickly because they see large amounts of cases and have well-organized training. But those physicians who did not enter tertiary hospitals lack continuous training, therefore patients would rather go to big hospitals to seek medical care than stay in their local facilities. The current goal of health care reform in China is to set up a comprehensive primary care system that will cover the basic medical needs of patients. There is a gap between the ever-growing need for high quality medical care and the low confidence in family doctors. This situation demands the Chinese government to make efforts to train more internists and general practitioners.
What are some of the most significant challenges that physicians throughout China face? What are your thoughts on the best way to meet those challenges?
The challenges doctors face in China include relatively low income, undesirable social status, and a tense doctor-patient relationship. I think the best way to meet these challenges is to make doctors understand their own value, rebuild their social responsibilities, professionalism and honor, strengthen their communication with patients, raise their wages, and get the society to recognize doctors’ value through reasonable means.
Change is the most significant challenge physicians in China are facing. The main goal of health care reform in China is to form “a linked reformation in medical care, insurance and medication.” Separating drug sales from medical practice means hospitals are not able to balance their budget with profit from selling medication, and physicians will be allowed to practice without the restriction by their employment hospitals once they are licensed. The Government has to invest a large amount of money in the primary care system, and abandon its tight control on secondary and tertiary hospitals. In this situation, every physician in China will face potential changes in their future career. The best way to solve those challenges is to establish high standard training systems to ensure that each physician can get continuous training wherever they are.
What can other countries learn from your health care system?
Managing the largest population in the world is the most challenging task that China’s health care system faces. The system has become stable after generations of improvement, yet it still has room to get better. Such experience is valuable to other countries, especially for those facing similar problems.
Through tight control of the cost by the Government, the Chinese health care system is both efficient and cost effective. Most patients can get their primary health care within their community, while having the option to see a doctor of their choice in larger hospitals if they are willing to pay. The costs for treating most diseases are affordable in urban areas. Because the economy in China varies greatly among cities, local authorities determine the medical insurance policy based on their ability to pay, and effectively controlling the liability on the people.
Are enough young physicians in China choosing to be internists? What makes them choose (or not choose) to practice internal medicine?
Not enough young physicians are choosing to be internists. The number of practicing internists and the nation’s population is in disproportion.
The reasons that young physicians do not choose practice internal medicine include:
- Incomes are not attractive compared to other careers or subspecialties.
- Less desirable career path.
- Heavy work load and not enough time to take care of their own family.
- Risk of malpractice lawsuit is high. More patients blame doctors for the difficulty and high cost of getting medical services.
What advice would you give to someone who is thinking about going into internal medicine?
- Passion is critical if you hope to enjoy a career in internal medicine. Therefore, spend enough time to understand this career, and make sure you will love the job before making the decision. Talking to people who have worked in internal medicine for more than 10 years would be helpful.
- Always keep your curiosity.
- You will always meet difficulties; complain less and do more to improve.
- Share your decision with your family and get support from them.
- Have a solid foundation for internal medicine, and do not enter a subspecialty too early.
- Have good clinical reasoning, communication skills and a sympathetic heart.
Several years ago, I met two senior internists at the ACP conference. They said their training was not comparable to the current internal medicine residency, to which I agree with. I also agree that the training in the Emergency Department, managing critically ill patients in hospitals, is very important to a doctor’s practice in the future, even for general practitioners or PCPs in clinics or communities. These are primary competencies and will facilitate prompt management of sick patients, disease containment, and decreasing hospitalization and ER admissions, especially when primary care health systems have not been established in China.
You have attended several ACP Internal Medicine Meetings in the past. Can you describe your experience?
It was an honor to become an ACP fellow in 2012, and I attended my first ACP conference as the representative of China, designated by the Presidents of the Chinese Society of Internal Medicine. I found that, every year at ACP’s Internal Medicine Meeting, new themes are proposed to address important issues. Attending these meetings is a great learning experience, and it has improved my practice.
What is the major appeal that keeps you coming back?
Getting a global perspective on medicine by meeting colleagues worldwide and learning about new developments in the field of internal medicine. My take is that ACP’s mission is to improve people’s health by training physicians to reach the highest level of care and professionalism, a direction we may consider.
What topics or special sessions at the Internal Medicine Meeting most interest you?
I am most interested in sessions for Hospital Medicine, Clinical Education and Early Career Physicians, Residents/Fellows. I hope these will give me enough insights about planning curriculum for junior internists training in my hospital. The clinical skills, quality improvement sessions, and workshops are also very interesting.
What ACP resources are more relevant to elevate the practice of Internal Medicine in China and to ultimately improve patient care?
Physicians in China could benefit from ACP resources, especially clinical guidelines and publications, while the most valuable would be resources for obtaining CME. If ACP could collaborate with Chinese colleagues led by PUMCH, inviting experts from ACP and China to train Chinese trainees based on their needs, I believe it will be very productive, as we have been doing with similar CME programs in China.
Please share your most memorable ACP experience.
The ACP Internal Medicine Meeting holds many small-scale training modules in miscellaneous formats and contents, including operation skills, PPT-based teaching, simulated case-based practice, etc. These are in addition to the larger lectures at the meeting. I have been most impressed by the clinical skill training modules for residents and medical students. They are organized well and receive very positive feedback. In the past several years, we also tried a similar format of teaching in our academic conferences.
I have also made a lot of friends by joining ACP. I appreciate their help a lot, and I have invited them to attend the national conference of internal medicine in China, visit PUMCH, and spread ACP’s value throughout China. My colleagues in China have translated the ACP Teaching Medicine textbook series, which has played an important role in faculty development for residency training. With our efforts together, more and more colleagues in China have become exposed to ACP. This year, I will attend the ACP Internal Medicine meeting with representatives from several other renowned medical institutions in China. By working together, we hope to strengthen the collaborative tie, promote the medical education and practice in both the U.S. and China, and improve health care in China.