The Role of General Practitioners in China's Medical and Health System

doi:10.12114/j.issn.1007-9572.2020.00.084

Abstract

Abstract: China is currently carrying out a new round of medical and health system reform，and general practitioners（GPs） play an important role in this medical reform.It is helpful to explore the value of GPs in the medical and health system to encourage various stakeholders to take measures jointly to promote the development of GP services.This article analyzed the current challenges faced by China's medical and health system from the aspects of basic medical coverage，medical resource utilization，medical treatment pattern，limitations of coping with chronic diseases，health cost flow，and doctor-patient relationship.It was proposed that GPs could play an important role in the following six aspects：to help to achieve the goal of "health care for all" in China；to balance the medical information asymmetry between doctors and patients and reduce excessive medical treatment in the medical system；to contribute to the formation of a reasonable medical treatment pattern and efficient use of health resources；to make medical services continuous，proactive，and interactive to meet the challenges of chronic diseases；to attract the attention to the prevention of diseases，so that the health input would get better output；and to improve the harmony of doctor-patient relationship.On this basis，this paper put forward some corresponding countermeasures and suggestions on how to better play the role of GPs in China.

Key words: General practitioners, General practice, Primary health care, Health care reform

摘要： 我国当前正进行新一轮的医药卫生体制改革，全科医生在此次医改中扮演着重要的角色，探讨全科医生在医疗卫生服务体系内的价值，有助于激励各方参与者共同采取措施，促进全科医生服务的发展。本文从基本医疗卫生服务覆盖范围、医疗资源使用情况、就医格局、应对慢性病挑战的局限性、卫生费用流向、医患关系等方面分析了目前我国医疗卫生服务体系面临的挑战，认为全科医生具有以下6个方面作用：有助于我国“人人享有卫生保健”目标的实现；平衡医患间医疗信息的不对称，降低医疗卫生服务体系内过度医疗；有助于形成合理的就医格局，高效使用卫生资源；使医疗服务具有连续性、主动性、互动性，应对慢性病的挑战；注重“疾病预防”，使卫生费用的投入得到较好的产出；提升医患关系的和谐度。同时，本文基于上述分析，对我国如何更好地发挥全科医生的作用提出了相应的对策建议。

关键词: 全科医生, 全科医学, 初级保健, 卫生保健改革

WANG Ronghua,WANG Suping. The Role of General Practitioners in China's Medical and Health System　[J]. Chinese General Practice, 2020, 23(4): 388-394. DOI: 10.12114/j.issn.1007-9572.2020.00.084.
王荣华,王素平. 全科医生在我国医疗卫生服务体系中的作用研究[J]. 中国全科医学, 2020, 23(4): 388-394. DOI: 10.12114/j.issn.1007-9572.2020.00.084.

References

［1］国务院.关于深化医药卫生体制改革的意见［Z］．2009.
［2］China's major health challenge：control of chronic diseases［J］．Lancet，2011，378（9790）：457．DOI：10.1016/S0140-6736（11）61232-4.
［3］Amanda Howe.《首尔宣言》解读：行重于言，但始于言［J］．中国全科医学，2019，22（4）：371-375．DOI：10.12114/j.issn.1007-9572.2019.04.001.
HOWE A.Actions speak louder than louds——but words are a start［J］．Chinese General Practice，2019，22（4）：371-375．DOI：10.12114/j.issn.1007-9572.2019.04.001.
［4］王洪兴，张韬，龚幼龙.基本医疗服务与基本公共卫生服务在“保基本”中的同质性分析［J］．中国全科医学，2014，17（19）：2201-2203，2207．DOI：10.3969/j.issn.1007-9572.2014.19.008.
WANG H X，ZHANG T，GONG Y L.The homogeneity analysis of "basis" in basic medical service and basic public health service［J］．Chinese General Practice，2014，17（19）：2201-2203，2207．DOI：10.3969/j.issn.1007-9572.2014.19.008.
［5］方鹏骞，杨兴怡，张霄艳，等．再论中国基本医疗服务的内涵［J］．中国卫生政策研究，2015，8（6）：52-56．DOI：10.3969/j.issn.1674-2982.2015.06.009.
FANG P Q，YANG X Y，ZHANG X Y，et al．Re-discussion on basic medical services connotation in China［J］．Chinese Journal of Health Policy，2015，8（6）：52-56．DOI：10.3969/j.issn.1674-2982.2015.06.009.
［6］READER G G，STARFIELD B.Primary care：concept，evaluation，and policy［J］．J Public Heal Policy，1993，14（4）：500．DOI：10.2307/3342881.
［7］STARFIELD B，SHI L Y，MACINKO J.Contribution of primary care to health systems and health［J］．Milbank Q，2005，83（3）：457-502．DOI：10.1111/j.1468-0009.2005.00409.x.
［8］STARFIELD B.Primary care：an increasingly important contributor to effectiveness，equity，and efficiency of health services.SESPAS report 2012［J］．Gac Sanit，2012，26（suppl 1）：s20-26．DOI：10.1016/j.gaceta.2011.10.009.
［9］秦江梅，张丽芳，林春梅，等．我国基层卫生综合改革进展［J］．中国全科医学，2017，20（22）：2683-2690．DOI：10.3969/j.issn.1007-9572.2017.22.001.
QIN J M，ZHANG L F，LIN C M，et al．Progress of comprehensive reform of primary health care in China［J］．Chinese General Practice，2017，20（22）：2683-2690．DOI:10.3969/j.issn.1007-9572.2017.22.001.
［10］Chinese doctors are under threat［J］．Lancet，2010，376（9742）：657．DOI：10.1016/S0140-6736（10）61315-3.
［11］毛正中，蒋家林.我国诱导需求的数量估计［J］．中国卫生经济，2006，25（1）：65-67．DOI：10.3969/j.issn.1003-0743.2006.01.020.
MAO Z Z，JIANG J L.Estimating quantity of induced demand for medical services in China［J］．Chinese Health Economics，2006，25（1）：65-67．DOI：10.3969/j.issn.1003-0743.2006.01.020.
［12］付雁南.“注射大国”的医疗现状［J］．共产党员，2011，64（3）：53．http://xueshu.baidu.com/usercenter/paper/show?paperid=d4d1b612d9d1f77e40397c0ff9df4e19&site=xueshu_se&hitarticle=1.
［13］应向华，陈洁.上海市医用CT配置和使用情况研究［J］．中国卫生资源，2008，11（5）：210-211．DOI：10.3969/j.issn.1007-953X.2008.05.005.
YING X H，CHEN J.Study on medical CT allocation and utilization in Shanghai［J］．Chinese Health Resources，2008，11（5）：210-211．DOI：10.3969/j.issn.1007-953X.2008.05.005.
［14］国家卫生健康委.2018年我国卫生健康事业发展统计公报
［EB/OL］．（2019-05-22）［2019-08-31］．http://www.nhc.gov.cn/guihuaxxs/s10748/201905/9b8d52727cf346049de8acce25ffcbd0.shtml.
［15］孙震，鲁军宜.分级诊疗如何实现？68.3%受访者不信任社区医院医生水平不高、医疗资源少、医药费贵是社区医院遭冷遇的主因［N］．中国青年报，2014-04-15（07）.
［16］金生国.深化改革加快全科医生队伍建设［EB/OL］．（2018-09-12）［2019-09-04］．http://www.medmeeting.org/Home/Prog ram/6712?dateid=3546&hallid=8475.
［17］钟颖，吴春玲，陈冠桦，等．广州市居民社区首诊意愿及影响因素研究［J］．中国全科医学，2016，19（16）：1924-1927．DOI：10.3969/j.issn.1007-9572.2016.16.016.
ZHONG Y，WU C L，CHEN G H，et al．Willingness for community first contact care among Guangzhou residents and influencing factors［J］．Chinese General Practice，2016，19（16）：1924-1927．DOI：10.3969/j.issn.1007-9572.2016.16.016.
［18］成王金，朱益民.基层首诊实施的制约因素与促进对策［J］．卫生经济研究，2017，34（10）：56-58．http://xueshu.baidu.com/usercenter/paper/show?paperid=ee07627e5b228adee8e445a960c1f335&site=xueshu_se&hitarticle=1.
［19］REYNOLDS R，DENNIS S，HASAN I，et al．A systematic review of chronic disease management interventions in primary care［J］．BMC Fam Pract，2018，19（1）：11．DOI：10.1186/s12875-017-0692-3.
［20］WAGNER E H.Chronic disease management：what will it take to improve care for chronic illness?［J］．Eff Clin Pract，1998，1（1）：2-4.
［21］SCHMITTDIEL J A.Effect of primary health care orientation on chronic care management［J］．Ann Fam Med，2006，4（2）：117-123．DOI：10.1370/afm.520.
［22］BODENHEIMER T，WAGNER E H，GRUMBACH K.Improving primary care for patients with chronic illness［J］．JAMA，2002，288（14）：1775-1779．DOI：10.1001/jama.288.14.1775.
［23］邓峰，周忠良，高建民，等．2009—2013年中国医改主要投入产出分析［J］．中国循证医学杂志，2015，15（8）：887-891．DOI：10.7507/1672-2531.20150150.
DENG F，ZHOU Z L，GAO J M，et al．Empirical analysis of the main input and output of healthcare reform in China from 2009 to 2013［J］．Chinese Journal of Evidence-Based Medicine，2015，15（8）：887-891．DOI：10.7507/1672-2531.20150150.
［24］徐玲，孟群.第五次国家卫生服务调查结果之二：卫生服务需要、需求和利用［J］．中国卫生信息管理杂志，2014，11（3）：193-194．DOI：10.3969/j.issn.1672-5166.2014.03.01.http://www.cnki.com.cn/Article/CJFDTotal-WSGL201403007.htm.
［25］武留信.中国健康管理与健康产业发展报告（2018）［M］．北京：社会科学文献出版社，2018.
［26］颜婕.转型期医患关系紧张根源分析与对策思考［J］．中国医院管理，2010，30（11）：87-88．DOI：10.3969/j.issn.1001-5329.2010.11.041.http://www.wanfangdata.com.cn/details/detail.do?_type=perio&id=zgyygl201011041.
［27］AN J G.Which future for doctors in China［J］．Lancet，2013，382（9896）：936-937．DOI：10.1016/S0140-6736（13）61928-5.
［28］HUANG S L，DING X Y.Violence against Chinese health-care workers［J］．Lancet，2011，377（9779）：1747．DOI：10.1016/S0140-6736（11）60732-0.
［29］张妮莉，赵静.基于期望差异理论的医患信任危机研究［J］．中国医学伦理学，2014，27（3）：391-393.
ZHANG N L，ZHAO J.Research on credibility crisis in doctor-patient relationship based on expectation disconfirmation theory［J］．Chinese Medical Ethics，2014，27（3）：391-393.
［30］FENDALL N R E.Declaration of Alma-Ata［J］．Lancet，1978，312（8103）：1308．DOI：10.1016/s0140-6736（78）92066-4.
［31］FUNG C S，WONG C K，FONG D Y，et al．Having a family doctor was associated with lower utilization of hospital-based health services［J］．BMC Health Serv Res，2015，15：42．DOI：10.1186/s12913-015-0705-7.
［32］STIGLITZ J.Economics of the public sector［M］．2nd ed．New York：W.W. Nortion & Company，1988.
［33］王荣华，李云涛，赵玲，等．基层全科医生在医联体内的角色定位研究［J］．中国全科医学，2019，22（1）：5-9．DOI：10.12114/j.issn.1007-9572.2019.01.002.
WANG R H，LI Y T，ZHAO L，et al．Roles of general practitioners working in primary healthcare settings joining in a regional medical consortium［J］．Chinese General Practice，2019，22（1）：5-9．DOI：10.12114/j.issn.1007-9572.2019.01.002.
［34］LOWN M，LEWITH G，SIMON C，et al．Resilience：what is it，why do we need it，and can it help us［J］．Br J Gen Pract，2015，65（639）：e708-710．DOI：10.3399/bjgp15x687133.
［35］MAJEED A.Primary care in England：between a rock and a hard place［J］．J Ambul Care Manage，2013，36（2）：126-128．DOI：10.1097/JAC.0b013e3182887132.
［36］OTHMAN A A，WAGNER E H.Chronic illness management：what is the role of primary care［J］．Ann Intern Med，2003，138（3）：256-261．DOI：10.7326/0003-4819-138-3-200302040-00034.
［37］SAULTZ J W，LOCHNER J.Interpersonal continuity of care and care outcomes：a critical review［J］．Ann Fam Med，2005，3（2）：159-166．DOI：10.1370/afm.285.
［38］COULTER A.Patient engagement：what works［J］．J Ambul Care Manag，2012，35（2）：80-89．DOI：10.1097/jac.0b013e318249e0fd.
［39］SHI L.The relationship between primary care and life chances［J］．J Health Care Poor Underserved，1992，3（2）：321-335．DOI：10.1353/hpu.2010.0460.
［40］SHI L Y.Primary care，specialty care，and life chances［J］．Int J Health Serv，1994，24（3）：431-458．DOI：10.2190/bduu-j0jd-bvex-n90b.
［41］BAICKER K，CHANDRA A.Medicare spending，the physician workforce，and beneficiaries' quality of care［J］．Health Aff（Millwood），2004（suppl 3）：184-197．DOI：10.1377/hlthaff.w4.184.
［42］GULLIFORD M C.Availability of primary care doctors and population health in England：is there an association?［J］．J Public Health Med，2002，24（4）：252-254．DOI：10.1093/pubmed/24.4.252.
［43］于晓松，路孝琴.全科医学概论［M］．5版.北京：人民卫生出版社，2018.
［44］GREENFIELD G，FOLEY K，MAJEED A.Rethinking primary care's gatekeeper role［J］．BMJ，2016，354：i4803．DOI：10.1136/bmj.i4803.
［45］陈丽英.病人诊治过程的参与行为对病人满意度的影响［D］．杭州：浙江大学，2013.
CHEN L Y.The impact of patient participation behavior on patient satisfaction［D］．Hangzhou：Zhejiang University，2013.
［46］TINSEL I，BUCHHOLZ A，VACH W，et al．Implementation of shared decision making by physician training to optimise hypertension treatment.Study protocol of a cluster-RCT［J］．BMC Cardiovasc Disord，2012，12：73．DOI：10.1186/1471-2261-12-73.
［47］DE WAARD C S，POOT A J，DEN ELZEN W P J，et al．Perceived doctor-patient relationship and satisfaction with general practitioner care in older persons in residential homes［J］．Scand J Prim Health Care，2018，36（2）：189-197．DOI：10.1080/02813432.2018.1459229.
［48］SAULTZ J W，梁万年，李航.连续性照顾（一）［J］．中国全科医学，2002，5（7）：507-510．DOI：10.3969/j.issn.1007-9572.2002.07.002.http://med.wanfangdata.com.cn/Paper/Detail/PeriodicalPaper_zgqkyx200207002.
［49］汪雨潭，匡莉，赵婧革.全科医疗核心特征功能定义与内涵界定研究：可及性［J］．中国卫生政策研究，2017，10（5）：7-12．DOI：10.3969/j.issn.1674-2982.2017.05.002.
WANG Y T，KUANG L，ZHAO J G.Study on defining and conceptualizing of general practice：the accessibility of primary care［J］．Chinese Journal of Health Policy，2017，10（5）：7-12．DOI：10.3969/j.issn.1674-2982.2017.05.002.
［50］王荣华，李云涛，汤忠泉，等．我国居民签约家庭医生意愿率的Meta分析［J］．中国全科医学，2019，22（4）：395-401．DOI：10.12114/j.issn.1007-9572.2019.04.006.
WANG R H，LI Y T，TANG Z Q，et al．Rate of residents intending to sign a health service contract with the family doctor in China：a meta-analysis［J］．Chinese General Practice，2019，22（4）：395-401．DOI：10.12114/j.issn.1007-9572.2019.04.006.
［51］赵艳青.典型案例地区家庭医生签约服务实施路径研究［D］．北京：北京协和医学院，2018.
ZHAO Y Q.Study on the implementation path of family doctors contracting services in typical regions［D］．Beijing：Peking Union Medical College，2018.
［52］SIMON C，FORDE E，FRASER A，et al．What is the root cause of the GP workforce crisis?［J］．Br J Gen Pract，2018，68（677）：589-590．DOI：10.3399/bjgp18X700145.
［53］HAMMOND W E，BAILEY C，BOUCHER P，et al．Connecting information to improve health［J］．Health Aff（Millwood），2010，29（2）：284-288．DOI：10.1377/hlthaff.2009.0903.
［54］世界银行.创建健康和谐生活：遏制中国慢性病流行［EB/OL］．（2011-07-26）［2019-08-04］．http://documents.shihang.org/curated/zh/621841468023051158/Toward-a-healthy-and-harmonious-life-in-China-stemming-the-rising-tide-of-non-communicable-diseases.
［55］杨辉.从《阿拉木图宣言》到《阿斯塔纳宣言》：全科医学发展是实现全民健康覆盖的重中之重［J］．中国全科医学，2019，22（1）：1-4．DOI：10.12114/j.issn.1007-9572.2019.01.001.
YANG H.Declarations from Alma-ata and Astana：development of general practice is a top priority for achieving universal health coverage［J］．Chinese General Practice，2019，22（1）：1-4．DOI：10.12114/j.issn.1007-9572.2019.01.001.

[1]	TANG Haoqing, LI Mingyue, LONG Ren, ZHU Yinbo, LIANG Weihuan, ZHU Ping, ZHAO Wei, ZHAO Yang, LIU Xiaoyun. Management Burden of Diabetic Mellitus Patients with Multimorbidity among Middle Aged and Older Adults: a Cross-sectional Survey in 6 Community Medical Institutes of China [J]. Chinese General Practice, 2026, 29(32): 4786-4797.
[2]	CHENG Yu, YANG Rong, LONG Ren, LIAO Xiaoyang, ZHAO Yang. Study Design, Implementation and Case Analysis of Randomized Controlled Trials in Community-based Primary Care Settings [J]. Chinese General Practice, 2026, 29(31): 4528-4535.
[3]	HAN Leyang, ZHENG Huixian, TIAN Yiran, TANG Haoqing, LONG Ren, LI Daihan, LIU Xiaoyun. Measuring Integrated Services for Rural Chronic Disease Patients Based on Formative Measurement Theory [J]. Chinese General Practice, 2026, 29(31): 4543-4550.
[4]	LIU Danyi, SU Chonghong, YU Yaqi, ZHANG Haihao, LUO Hongchi, LUO Tianxiang, WANG Chen, WANG Hui, MA Hanying, ZHAO Tiefu. Reliability and Validity Analysis of the Chinese Localized Version of EUROPEP in Primary Healthcare Institutions in Beijing [J]. Chinese General Practice, 2026, 29(31): 4551-4558.
[5]	LI Lan, LIU Lidi, ZHANG Peng, LI Dongze, YANG Ziyu, CHENG Yonglang, LIAO Xiaoyang, WAN Zhi. Lifestyle Intervention-based Weight Management: an Analysis of Key Highlights from the Partial Update of the 2025 NICE Guideline Overweight and Obesity Management (NG246) [J]. Chinese General Practice, 2026, 29(30): 4353-4359.
[6]	LI Wanyu, JIN Hua, ZHANG Qianqian, YU Dehua. Knowledge, Attitude and Practice of Community-based General Practitioners in Implementing Proactive Health Management in Shanghai and Their Influencing Factors [J]. Chinese General Practice, 2026, 29(28): 4157-4163.
[7]	WANG Yan, ZHOU Meiqiong, NI Ming. Application of Multi-disciplinary Team-based Situational Simulation Teaching Method in Cultivating Comprehensive Diagnostic and Therapeutic Competencies of General Practitioners [J]. Chinese General Practice, 2026, 29(28): 4086-4091.
[8]	DENG Wei, HUANG Mengting, YI Shengli, LIN Yang, XU Lidan, REN Zhexue, ZHU Xiuqiong, LI Yesha, REN Mengge, KE Dazhi, LI Guiqiong, WU Zhiqin, LUO Aoran, HE Fapei. Training and Effectiveness of AI-enabled Clinical Reasoning in General Practice [J]. Chinese General Practice, 2026, 29(28): 4078-4085.
[9]	FU Jiarui, LI Muhao, DU Yue, SHI Yu. Institutional Incentives, Resource Coordination, and Team Empowerment: a Qualitative Study of the Multidimensional Dilemmas and Strategies for Gold Medal Family Doctor Team Development in Tianjin [J]. Chinese General Practice, 2026, 29(27): 3899-3905.
[10]	LI Yahui, XIE Kun, LIAN Lu, ZHANG Huaiping, CHEN Jiaying. Analysis of the Current Status of Professional Competence of Primary Care Doctors in China Based on the Iceberg Model [J]. Chinese General Practice, 2026, 29(27): 3891-3898.
[11]	HE Guoshu, REN Jingjing, ZHU Jiahong, MA Fanghui, SUN Wenping, LIU Lei, YIN Ankang, TANG Wenjuan. A Comparative Study of the Regional Characteristics of General Medically Unspecified Disease Patients in Northern and Southern China Based on Multi-center Real-world Data [J]. Chinese General Practice, 2026, 29(26): 3745-3751.
[12]	ZHAO Yawen, WANG Jieping, DU Xueping, WU Wei, YAN Wei, ZHOU Xiaoxia, GUAN Yajie, LI Qian, LI Haodong. Analysis of Disease Characteristics of Outpatients in the Department of General Practice at a Tertiary General Hospital in Beijing [J]. Chinese General Practice, 2026, 29(26): 3733-3738.
[13]	ZHAO Zezhou, WANG Jieping, DU Xueping, YAN Wei, WU Wei, LI Qian, ZHAO Yawen, LI Haodong. Analysis of Disease Characteristics of Inpatients in the Department of General Practice at a Tertiary General Hospital in Beijing [J]. Chinese General Practice, 2026, 29(26): 3739-3744.
[14]	ZHANG Jingyu, ZHANG Yu, LU Xinxi, LI Min, XU Lu, ZHENG Jundi, NIE Yuxian, SHI Qiuling, DAI Xiaojun. The Current Status and Needs of Community-based Cancer Patients Management from the Perspective of Stakeholders [J]. Chinese General Practice, 2026, 29(25): 3664-3669.
[15]	ZHOU Yuhan, MIN Yuqi, GUO Zhou, YANG Min, YUE Lu, HE Meichen, ZHOU Hairong, WANG Yongchen. Opportunities and Challenges for General Practitioners in the Age of Artificial Intelligence [J]. Chinese General Practice, 2026, 29(25): 3563-3568.