More than 30 percent of the income of doctors training doctors is difficult to solve the problem of food and clothing
2022-06-27: [Article Link] Even with a cold fever, Chinese patients choose large hospitals in large cities because they consciously feel that the community or village hospitals around them are not sufficiently reassuring.
It is also an EU-American patient who has sought treatment for common diseases, and most of the family doctors in the community are his first option, because he knows that there may be a difference between the level of his family doctor and that of the big city doctor, but that the latter is sufficient to guarantee a basic level of treatment in the face of common diseases.
The source of this trust is the system of standardized training for inpatients.
In the developed countries of Europe and the United States, this three-year short-term, long-term five-year training programme, called “train” by doctors, allows a medical student to grow into a single doctor in a safe environment. It also gives the patient the assurance that he or she will be handed over to a trained doctor without having to go to a major hospital or a hospital attached to a medical school for minor illnesses. In order “to promote the equalization of medical services and to alleviate the persistence of large hospitals in a `war state'”, a document issued by the State Council in 2009 clearly proposed for the first time that China should “establish a system of standardized training for inpatient doctors”.
In 2013, the Guidance for the Establishment of a Standardized Training System for Inpatient Doctors was officially issued, setting out a timetable: By 2020, China will have basically established a regularized training system for inpatient physicians, and all new undergraduate and higher-level clinical practitioners will have received regular training for in-patient physicians. In 2015, the country began a comprehensive training campaign for inpatients. Today, there have been three batches of more than a thousand national training bases, and Chinese doctors are running almost into the age of discipline.
Basic hospitals complain that there is a shortage of people and that they need to be trained before they can take up employment; medical students have written that after writing their own medical records, doing chores, and three years of training as cheap labour, “the love for medicine has faded a little bit...”; even more so, the People's Daily post asks: “Does the training for medical homogenization remain questionable?”
So, what's going on in China with this medical training system, which has proved to be effective in many countries and regions?
Doctor, middle school or poverty line?
Training means that a medical student cannot work directly after graduation, but requires systematic clinical training in a training hospital as a resident. During that time, they were usually close, no longer students, but were still not hospital employees, and were thus unable to receive a normal salary. In such an embarrassing situation, they had to go through three years. “Poverty, sarcasm and discrimination are the dilemma that the vast majority of trainers will face over the last three years.” A trainer told eight questions.
“Stable low incomes sustain the basic needs of day-to-day life, with no extra cost per month”, as one doctor has done in his own time of practice.
In the rules of the birch garden, it's said: "Is it possible to deliver by-products?"
Income and treatment are almost all the problems that doctors are most ill with since the system of discipline was fully introduced in China.
In 2020, a survey of 3020 trained doctors was carried out in the Garden, and it was found that nearly 30 per cent (27.5 per cent) of trained doctors said that they earned less than 1,000 Yuan per month, 8 per cent of whom said that they had “no income” during the training period and that they earned more than 3000 yuan per month, or 32.3 per cent. Even among those who earn more than $3000 a month, 50.6 per cent are trained by the community and 44.9 per cent by the unit - which means that most of the doctors who come to train are no longer students, and that more than 3,000 of them may have to support their families.
To earn money to feed their families? In developed countries, this is not the end of the bargain.
A medical education expert from the United States told people at eight points that the training income was enough to “make it possible for them to buy mortgages during the training phase...”.
As described in a book by China Association and Medical University Press, " Going to America for Medical Practice ", in the United States doctors, although they earn much less than independent doctors, are mostly able to reach the level of their personal median income in the region. Indiana's gastrointestinal liver doctor concluded that in the United States, with the income of a trained doctor, “one person can live at will, and one family can live at a minimum. However, in China, a young pedagogic doctor in the capital city of an eastern province mentioned to the public at eight a.m. that his training income was “approximately 1,300 Yuan a month, enough to eat”. In the city where Sien-seng is located, social wages have exceeded 5,000 Yuan in recent years and the minimum wage set by the Government has exceeded 2200 Yuan. Although doctors’ education experts remind eight points that instead of looking at the “wages” that they pay each month, they should look for the long term and look ahead to the future after the end of the practice. One fact that cannot be changed is that the severe income situation of three years of training is causing the loss of young medical students.
According to a survey conducted by Zhang Yingmei of the School of Public Health of Kunming Medical University on six training bases in Yunnan province, the low income is even a major reason for some trainers to opt out. “Physician is like a cool divorce” and I found out that the hospital wasn't fit for myself, and that one of the web users left a message in the "Physician Heavens" of Ding Xiang’s Garden, and he thought he was probably not going to be a doctor anymore.
Many students say to eight points that they have worked hard to read books for five, eight or 12 years, but after graduation they have to undergo three years of regular training in low-income status, and that it is unacceptable to look at peers who spend many years on the job early, buying houses, getting married and having children, even if they are not able to cope with subsistence. However, many doctors, even medical students, have expressed their need for discipline in their own right to eight points. As medical education experts mentioned earlier, medical students who have graduated from school, regardless of their educational level, are essentially “finished” doctors, even below the “basic” standard, who have to undergo normative training to acquire basic clinical skills and become qualified doctors. The problem is that it's almost just an input.
In 2014, when China officially launched the construction of a standardized training system for in-patient physicians, the former National Commission on Human Rights (CNSS) specified that the central fiscal authority would provide specific financial support for the standardized training of in-patient doctors from 2014 onwards, with a financial subsidy of 30,000 Yuan/person/year. In that year, Chinese residents had a disposable income of 20167 Yuan. In terms of national averages, the difference between the subsidy of a pedagogic doctor and the disposable income of a normal urban resident was not large.
In contrast, in the state of Illinois, the median income tax for individuals across the state is more than 40,000, and the annual salary for doctors is more than 40,000, according to the data provided in the book " Going to the United States of America ". In Chicago, the average annual salary of a trained doctor rose to 50,000 with the median local income; in New York, the annual salary of a trained doctor rose to 60,000. In addition, in China, the central financial support rate of 30,000 Yuan has not increased in seven years since the criteria were established in 2014, except for a slight adjustment in the percentage of the individual component. Today, in many provinces, 80 per cent of 30,000 Yuan will be used to subsidize the training of doctors, i.e., from about 20,000 Yuan/person-in-person years to 24,000 Yuan/person-in-person years. According to the latest statistics of the National Statistical Office, the disposable income for residents in 2021 was 35,128 Yuan, and for urban residents 47,412 Yuan.
A medical education expert told the public that, in the United States, the cost of training a resident was largely funded by the United States federal health insurance, and that self-financing from the federal Veterans medical system and various other projects would contribute in part. Given the wide variation in the level of economic development across China, it was difficult to expect that the financial burden of individual subsidies for all normative training would be met, and that it would be possible to truly raise the income level of trained physicians only if the multiplicity of government, base and community inputs were achieved. However, there is no model to learn from where and by what criteria the input of the base and society comes from.
At present, in addition to the central financial support, the provincial administrations also subsidize the training of trainers, but the amounts vary considerably and are limited, depending on local financial capacity and strength. In some of the more subsidized developed provinces, this benefit from provincial finance can reach 18,000 Yuan/person-years, while in other remote provinces it is only 3,300 Yuan/person-years. In addition, at eight points, it is known that most of the training facilities also provide a certain amount of assistance to the trainers. However, for a variety of reasons, the difference in the amount of benefits granted to the trainers at the base level is also evident.
As the founder and promoter of the Chinese system of discipline, Liu Jin, Director of the Anesthesia Centre of the Washington Hospital, has always been attacked and criticized for this issue.
In fact, Liu Jin was not unaware of the problem, and in 2003-2013 he hoped to earn 120,000 per year for his students when he submitted proposals for the establishment of a training system to the National People's Congress for a continuous period of 10 years.
In 2021, on the day of his 65th birthday, Liu Yin donated a $100 million scholarship for the conversion of scientific research for the establishment of the China-West Hospital Specialized Training and Development Fund. When he was interviewed in China’s Health Journal in the same year, Liu was slightly reduced in expectations.
He stated that he would seek an annual subsidy of 100,000 Yuan for each trained doctor.
Write medical records, do chores. Can you train a real doctor?
In addition to the complaints about income, another complaint from Dr. Physician was that he could not learn anything and even became a “low-cost labourer” in the rota.
A trainee at a local municipal training hospital complained to eight points: daily work is to write medical records; participation in house searches is merely formalistic; few cases are discussed, mainly for photography purposes.
He sometimes wonders how he will go after three years of practice as a doctor who has rarely been involved in receiving and receiving medical advice.
On the other hand, it is not just the doctors who learn, but the doctors who learn. According to the original intent of the system, the goal is to develop qualified doctors who can stand alone, and if this is not achieved, it may be in the interests of all patients.
"The doctor's profession, if you don't do it right, you're going to get killed." Liao Chi Lin, Secretary of the Party, West China Gate Hospital, stressed.
To do so, repeated observation and exercises are essential, and this is also the purpose of the training facility’s involvement in the rotation and routine work of doctors.
Medical students who have graduated from school after passing a training test with a certain phase-out rate have entered their training phase. Over a period of three years, these trainers are required to rotate from two months to several months in different sections, and the most important of which is to acquire the skills to treat the basic and multiple diseases of the corresponding unit during the course of the transition. In the United States, Medical Travel to the United States mentions that in the areas of internal medicine and pediatrics, doctors help to manage patients in high-aged hospitals, 10 in the first year, 20 in the second year and almost half in the third year.
According to an overview in the Chinese Journal of Lung Cancer, in the third year a number of United States doctors are required to perform intermediate surgery such as cyst removal, breast removal, etc., and to start emergency consultations. Ultimately, after five years of training for a U.S. general surgeon, a medical college graduate will be an independent general surgeon who will be able to work independently, who will be largely competent in general surgical clinical work and who will be able to complete the normal general surgical procedure independently. In China, however, the situation of doctors is often different.
A number of trainers told him that during the training period, when the clinical room rotated, writing medical records often took up half a day or more of their time. Although the writing of medical records is the basic function of doctors, the ease with which they can be rapidly skilled and spend their time here in the long run makes them feel like workers on the water line who are mechanized daily, with little improvement. Throughout the process, doctors often have little or no contact, or even little access, when they are trained in many training bases.
There is a reason why important medical treatments are not available to trained doctors.
There is no independent worker and no identity in the hospital, and all the payees and those in charge of the act are teachers.
In other words, students are responsible for their behaviour. In order to avoid the risk of medical accidents as much as possible, some teachers and training institutions tend to involve trainers in relatively low-quality work that is less risky – such as writing medical records, sending samples for examinations, taking inspection reports, etc. – far from the core of clinical activities.
A trainee student says that there is a significant difference between being able to participate in core work such as diagnostics and teaching teachers. Nor is there a teacher who is not willing and willing to take responsibility, and if he is recognized as capable, the teacher will be willing to let the trainee diagnose and dispose of it under his supervision.
On the other hand, teachers are clinical doctors themselves, not only in charge of teaching, but also in charge of patient consultations, which is a fundamental difference between teachers and full-time teachers in schools. In the more popular large training base hospitals, where some sections are severely understaffed and extremely busy, too high expectations for teachers may not be justified in themselves. A number of trainers told him that they were learning on their own initiative throughout the training process and that they could only communicate with themselves “on occasion”.
A medical education expert told the public at eight a.m., and a more unacknowledged problem is that the training of doctors can be transferred to a section for as long as a few months, and that some of the teaching teachers will not be trained as “their own” in their subconsciouss, and will be preserved in their own teachings, and that the idea of “Church and starved teachers” still exists. How does the ability of the trainers grow? The Department of Continuing Education of the People’s Hospital at Beijing University, among others, has selected 15830 teachers who have been teaching inpatients from 2018 to 2020 at 310 training bases throughout the country to evaluate the impact of discipline on the competence of the trainers. The results show that while residential training has resulted in a significant increase in the competence of inpatients, the results have been lower than expected, both at the beginning and at the end of residential training.
An emergency training base has been set up for the first time.
Can you train a qualified trainer?
In 2020, all newly admitted medical practitioners with an undergraduate degree and above received regular inpatient training, and China officially entered an age of incompetence.
And behind that is the construction of a rapidly expanding pedagogic base.
From 2013 to the present, only nine years have passed since the total number of three training bases announced in the country has exceeded 1,000. Geographically, almost all provinces, except Hong Kong and Macao, have their own training bases. With regard to these emergency training bases, the Medical Technical College of the Xian Medical School, Rini et al. pointed out that: there are currently hospitals with different levels of residence, unequal resources, technologically advanced, well-equipped and leading teaching and scientific research, as well as developing general hospitals; there are teaching hospitals with many years of experience in management and hospitals that have never been clinically taught; there are central urban hospitals with excess and multi-clinical conditions; and there are general local hospitals with single cases. A medical education expert has made it clear to eight points that the national system of discipline is fast-tracked, that it is premature to establish the requirement that doctors above the scientific background must be trained in uniform national regulations, and that many areas with less resources and capacity are not ready, which may pose problems over time. However, in regions with poor medical resources, such as the central west, is there a need to enforce the compulsory participation of doctors in training?
Another expert in medical education said to the public at eight points that, without the mandatory requirement of discipline, doctors in the backward areas would be less likely to meet the basic requirements, let alone promote them. He said, “I went to a district in a minority region where, for three years in a row, I could not get an assistant doctor before training, and only reduced the score; by training, the doctor would be sent here, at least to ensure that the doctor would meet the most basic requirements of the doctor. According to the medical education expert, the imbalance in medical resources is an objective historical problem, and the development of discipline is the first solution to the problem of “sustainability.” The historical problem cannot be used to negate the system itself, to tailor the objectives and requirements of the system to local conditions, and to use the system to actually help those regions with insufficient medical capacity to upgrade is all the more important. Thus, “although some western regions have insufficient medical capacity, there is still a need for a system of discipline, although standards may need to be lowered to meet the objective conditions in those areas”. Beyond the controversy as to whether the discipline itself is moving too fast, more questions are directed at the training base, which is built too quickly.
According to a trainer, the majority of social forums complaining that nothing has been learned at the training base are likely to complain about a lot of posts, and the majority may come from a poorly qualified and competent training base, which, if strong in itself, does not need to be “slowed down” on the Internet.
“Medical” before “teaching”, how can the capacity of a training base be ensured at a time when medical resources and capacity are still highly uneven? So, again, in the national document, a simple, brutal one-size-fits-all — the training base should in principle be a level-III level-A hospital or a qualified level-III specialized hospital.
However, a one-size-fits-all approach poses another problem. On the mainland China, the medical capacity of the provinces differs from one another, and there is no generalization between the tri-a and tri-a-hospital hospitals. Another disconcerting fact that medical capabilities are not always reflected in the system of discipline is that the “weak three aces” are hard-won crowns and the “non-tribes” who are powerful and do not qualify as a training base.
According to Mr. Zhao Yunwu, one-size-fits-all requirement for a “three-one-size-fits-all” hospital at the University of Anhui Medical Hospital, some hospitals in the eastern regions of Beijing and Shanghai that are below level A are unable to become training bases, have in fact achieved a significant level of combined medical, teaching and other capabilities, some of which are higher than the level III level A hospitals in the central and western regions. In the United States, where the system has been in operation for more than 100 years, training bases require only federal hospital certification and licensing, and there are no strict restrictions on the type and level of health-care institutions as long as training needs are met.
There are no level access restrictions, however, the United States Training Base has a mature and rigorous daily assessment that determines the fate and retention of these Training Bases.
In China, the evaluation of this residential doctor's training base was commissioned by the Scientific and Technical Education Department of the National Health and Health Council to be organized by the Chinese Medical Doctors'Association.
In July 2018, the Vice-President of the Chinese Medical Doctors' Association, Qi Jian, stressed at a start-up meeting of the Training Base that the “Assessment” was a disciplinary commission and a public prosecutor's office in the resident medical profession, and that it should focus primarily on the identification of problems and issues. The emphasis was on the strict application of indicators without artificially lowering the criteria and, in particular, on the issues reflected in complaints and evaluations, which must be verified on an article-by-article basis. In the actual assessment, the measure is broken down to be more than 85, 70 - 85, basic, 60 - 70, yellow and less than 60, red.
The so-called yellow card warning is a request for a modification of the deadline; the red card warning is a direct disqualifyment. From 2015 to July 2018, 15 training bases and 71 specialized training bases have been asked to do so, and 18 specialized training bases have been revoked.
It is worth noting, however, that the Chinese Medical Doctors' Association, as an industry association, does not have the power directly to disqualify the Physician Base and its specialized bases, but rather to “advise” the Commission to the Dependent Territories.
And behind the above-mentioned penalties, another worrying fact is that our evaluation of the pedagogic base is seriously behind schedule.
According to statistics, there were 859 training bases in the country by December 2020, before the release of the third batch of inpatient training bases. However, from the full roll-out of the 2015 training system to January 2021, there were only 384 evaluated training bases, less than half of all training bases.
In 2019, the Chinese Medical Doctors'Association published six batches of 15 reports on the results of the evaluation of the standardized training base for in-patient physicians; however, the results involved only 52 training bases, well below the number of training bases approved at that time.
A medical education expert mentioned to eight points that the system of inpatient training is a mature system in the West for more than a hundred years, while in China it rises in almost a decade, and you can't ask it to be perfect, yet what a good top-level design needs to do is to be fully motivated. On the subject of discipline, we have taken the first step bravely, but where does the operating funds of the entire system come from, and how can they be guaranteed? How are the three parties motivated by inpatients, teaching doctors and training bases? The solution to these problems is the key to the true determination of the success or failure of the system.
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