In China, specialty hospitals dominate the health care system and patients often bypass general practitioners.
“The problem is that most Chinese patients want to go to the huge thousand-bed hospitals. They don’t want to see doctors in their hometowns and communities because they’ve had bad experiences with general care,” says Royce K. Keilers, DO, who has been to China 15 times in the past seven years.
Attempting to improve care and save money, the Chinese central government has demanded that all of the country’s provinces move toward a primary care-centered model of health care delivery.
Since 2006, the osteopathic medical profession has been involved in efforts to train Chinese physicians in primary care. Originating as a partnership of the American Osteopathic Foundation, which provided seed money, and Heart to Heart International, which has diverse humanitarian projects in China, the profession’s China initiative focused on the Szechuan province at the beginning.
A retired family physician from La Grange, Texas, Dr. Keilers was the first osteopathic physician to take part in this initiative, traveling to China to educate officials and physicians about the role of family medicine. Once or twice a year after that, small teams of osteopathic family physicians would go to Szechuan for a week to provide didactic and clinical instruction.
While they felt their efforts were worthwhile, the three DOs who traveled the most to China decided that a more intense approach needed to be taken to effectively train large numbers of Chinese physicians in primary care.
“If you are in a country only once or twice a year, it’s hard to have the kind of impact you’d like to have when you consider the magnitude of what the Chinese are trying to accomplish,” says AOA Trustee William J. Burke, DO, who has been to China a dozen times.
Under the auspices of the American College of Osteopathic Family Physicians, Dr. Keilers, Dr. Burke and osteopathic medical school administrator Ronnie B. Martin, DO, established a new entity—the International Primary Care Educational Alliance (IPCEA)—to advance the recognition and development of primary care medicine around the world. At the start, IPCEA is limiting itself to China. But the alliance expects to broaden its reach eventually.
Funded partly by the Chinese government and partly by a medical device manufacturer, IPCEA’s maiden initiative is a three-year project in Shenzhen, a city of more than 15 million people in the Guangdong province, which borders Hong Kong. The objective is to thoroughly train an initial group of 20 non-primary-care specialists in family medicine. Once trained, these Chinese physicians will be expected to educate other Chinese medical specialists in primary care.
Beginning this past January, a team of three osteopathic physicians has traveled monthly to Shenzhen. Each month, the DOs stay for a week and educate the Chinese physicians on common conditions seen by family physicians, generally focusing on one organ system at a time. So far, the teams have trained Chinese physicians in diagnosing diseases of the cardiovascular, endocrine and gastrointestinal systems, as well as those of the skin and ears, nose and throat.
The curriculum covers the same material as an AOA-approved family medicine residency program. Before the DOs arrive each month, the Chinese physicians read the appropriate chapters in a family medicine textbook that has been translated into Chinese.
Although their prior medical education has been highly specialized, most of the Chinese physicians are trained in Western medicine
“We’re training doctors—not medical students—so we’re not going over all the basics,” Dr. Keilers says. “Our main goal is to get them to see the patient as a whole person. They need to learn that when you treat one area of the body, it affects another area.”
Each weeklong visit includes a half-day of lectures on common conditions addressed by family physicians and evidence-based guidelines for prevention and treatment. During the rest of the week, the DOs train the Chinese doctors in two clinics that were remodeled to U.S. standards at the request of IPCEA.
In a typical Chinese clinic setting, the doctor sits in a room and waits for patients to be brought in one at a time. “The Chinese general practitioners do not have otoscopes and ophthalmoscopes at hand,” Dr. Keilers says. “There is an examination table that is rarely used. The patient encounter consists mostly of talking and writing prescriptions.”
The redesigned clinics, which have a central nurses station, are well-equipped for patient care and teaching, he says.
The osteopathic physicians observe the Chinese physicians as they interact with patients, who have agreed to be part of the educational program. The DOs offer suggestions during the encounters and provide additional feedback after each patient leaves.
“We work with the Chinese physicians side-by-side in small groups—taking histories, doing physical examinations, developing care plans,” says Dr. Burke, the program’s educational coordinator. “And we hold small-group discussions about each case before we see the next patient.”
Training the trainer
A central feature of the Shenzhen initiative is the formation of the DO teams, each of which consists of two physicians who serve as teachers and one who serves as the program administrator. One of the teachers is always someone who has been to China previously.
“So every time we go, we have a lead physician who has been to China before and a second physician who is an experienced teacher but is new to the country,” Dr. Keilers says. “After each trip, we then have three physicians with China experience. We hope they will continue to be involved and go into other areas of China, as we start new projects.”
IPCEA has had no trouble recruiting osteopathic family physicians for Shenzhen.
“The way we have been recruiting is twofold,” Dr. Burke says. “First, we have a lot of connections within the osteopathic educational world, so we approached some individuals whom we knew would be excellent teachers. We also sent emails to directors of medical education, family medicine program directors and other ACOFP members, letting them know we were looking for volunteers.
“We received close to 60 responses from interested physicians. Based on their CVs and other factors, we made our selections. Unfortunately, we don’t have enough spots for every qualified DO who wants to go.”
In the second year of the Shenzhen project, DO teams will go to China every other month. In the final year, the visits will be quarterly. After completing their training, the Chinese physicians will undergo an examination and certification process.
“The DOs who have gone to China are always impressed with the Chinese doctors, who are so enthusiastic about learning,” Dr. Keilers says. “And for almost all of the osteopathic physicians, their China experience has been one of the highlights of their life.”
The Chinese physicians, in turn, have given the IPCEA high marks, according to Dr. Keilers. During a six-month review of the Shenzhen program by Chinese officials, the 20 doctors completed a survey. Approximately 90% responded that they were satisfied with the program.
“One doctor commented, ‘I used to refer hypertensive patients to the hospitals,’ ” Dr. Keilers says.“ ‘Now I feel confident in prescribing medications and telling them guidelines to follow. The patients are convinced.’ ”