关键词: 全科医生, 亚专长, 医疗服务能力, 德尔菲法, 拓展职责

Abstract: Background　The expansion of responsibilities in general practice niche in China is still in its early stages, facing challenges such as insufficient standardized training and a lack of unified assessment and certification mechanisms. There is no consensus within the industry regarding the necessity, pathways, and models for developing sub-specialty capabilities in general practitioners across management, teaching, and clinical practice. Objective　Taking the expanded role in the international general practice niche as a reference, combined with the domestic model of combining general practice and specialization, this study adopts the Delphi expert consultation method and questionnaire survey method to explore the necessity, main paths, and training methods of cultivating sub-specialty capabilities of general practitioners. Methods　Based on the literature analysis and the previous research results on the development of the integrated general and specialized medical capabilities of community health service centers in Shanghai, we have initially proposed the subspecialty capability item pool for the training of general practitioners.From March to July 2024, we adopted the Delphi expert consultation method, with 60 experts as the research subjects for consultation and argumentation. Through two rounds of consultation, we determined the items regarding the role and necessity of cultivating subspecialty capabilities among general practitioners. At the same time, we surveyed the experts' tendencies regarding the training paths and models, designed the questionnaire dimensions, and the contents included: the training methods for the sub-specialization capabilities of general practitioners, the training time stages, the knowledge and skills categories, the preference for professional direction selection, and the assessment and recognition institutions, etc. Results　The effective response rates for both rounds of expert consultation questionnaires were 100.0%, with expert authority coefficients of 0.92 and 0.94, and expert coordination coefficients of 0.146 and 0.165, respectively (P<0.001) . After two rounds of expert consultation, a set of items regarding the role and necessity of subspecialty competencies for general practitioners was finally formed, consisting of 3 first-level items and 15 second-level items. In terms of the role and necessity of cultivating subspecialty abilities among general practitioners: the mean importance scores for the 3 first-level items (the role of developing subspecialty abilities among general practitioners in primary healthcare; the coordination and complementarity between general medical basic work and specialized disease/subspecialty work; the necessity of developing subspecialty competencies for general practitioners) were all between 4.90 and 4.93, with full-score rates ranging from 88.3% to 91.7%, and coefficients of variation ranging from 0.05 to 0.06; the mean importance scores for the 15 second-level items were all between 4.42 and 4.98, with full-score rates ranging from 45.0% to 98.3%, and coefficients of variation ranging from 0.03 to 0.13. In terms of the pathways and modes for developing subspecialty competencies for general practitioners: 96.7% (58/60) of the experts chose specialist training in tertiary medical institutions with training qualifications for general practitioners, 93.3% (56/60) chose apprenticeship training (supervised by experts from tertiary medical institutions with training qualifications) ; 78.3% (47/60) of the experts chose the stage of attending physician title, and 11.7% (7/60) chose the stage of resident work after standardized training. Conclusion　The cultivation of expanded responsibilities in general practice niche is a practical logic that must be promoted for the development of primary healthcare. It is advisable to establish the "attending physician stage" as the starting point for the development of niche, and adopt the current strategy of "advanced training in tertiary hospitals combined with a mentorship system". Prioritize the development of subspecialties in dermatology and rehabilitation, and focus on stimulating and cultivating niche outside of hospital departments.

Key words: General practitioners, Sub-specialty, Medical service ability, Delphi method, Extended roles