How on-the-job training improves general practice service teams’ understanding of GPs’ roles in China: A qualitative case study

China has introduced series of policies to improve the professional self-image of GPs, however, Chinese general practitioners (GPs) generally have a low professional identity. This study evaluated the effects of on-job-training for medical health professionals that focuses on the recognition of GPs’ roles. Methods At a representative training base in Guangdong Province, the most economically developed province in Southern China, 62 workers from community health service centers underwent training for 6 months according to a before-after self-controlled design. A specic module related to professional value recognition was integrated into the training course. Trainees were invited to participate in the open-ended self-questionnair survey. Thematic analysis was used to explore themes within the data. Kappa test was used to compare consistency of career prospects before and after the training. present a discrepancy between the intentions of policies and their implementation.


Background
Since the 1980s, the health service system in China has emphasized medical care while ignoring disease prevention. One reason for this is the expansion of specialized medical services; with the increasing size and in uence of top medical centers, highly competent doctors are constantly being recruited from smaller local hospitals, thereby diminishing service capacity at the latter. To address issues such as congestion of medical services at high-level hospitals, tense doctor-patient relationships, and the increasing economic burden associated with the support of medical services, in 2009 the Chinese government implemented a series of health system reforms with the aim of establishing an extensive, high-quality network of community health services and changing the mode of health services from disease-to health-centered.
The government thus strengthened the training of general practitioners (GPs) and promoted the development of general practice services in communities. In 2010, the National Development and Reform Commission and six other ministries and commissions issued the Plan for The Construction of Community-level Medical and Health Teams Focusing on General Practitioners, which proposed that 300,000 GPs be trained through various channels by 2020, with the goal of having two to three GPs per 10,000 urban and rural residents.
The government adopted two major approaches to training GPs. One approach, known as "5 + 3", consisted of 5 years of university study plus 3 years of standardized hospital training. Under this system, it took years for students to become quali ed GPs. The second approach was the post transfer pattern, in which specialists from community health service centers were sent to a speci c training base for a 2-year training course. After passing the examination and assessment, they would be quali ed to practice general medicine. The latter was the main strategy used to increase the number of GPs and by April 2019, the total number of GPs trained in this manner had reached 150,000 [1] .
In order to consistently improve the capabilities of GPs, various on-the-job training programs were implemented; by April 2019, an average of 130,000 GPs were being trained per year [2] . However, despite the rapid increase in their numbers, GPs in China continue to exhibit low professional identity, as evidenced by the high turnover and job burnout rate. A survey conducted in Hubei province in 2015 showed that 78.35% of GPs had a moderate or high intent to resign [3] , and a national cross-sectional survey conducted from October 2017 to February 2018 showed that 41.19% of GPs experienced a high level of job burnout [4] . Studies conducted in many provinces including Zhejiang, Shanxi, Jilin, and Anhui reported similar ndings [5][6][7][8][9][10] .
Intent to resign and job burnout are related to professional identity [11,12] . However, there has been little research on the professional identity of GPs in China; it has been suggested that this is dynamic and depends on social context. A GP may have self-awareness with respect to his/her professional identity and a strong desire to consistently provide primary medical service to patients as well as public health and health management services [13] . The low professional identity among Chinese GPs has been deduced from studies on job satisfaction, turnover, job burnout, professional reputation, professional development potential, work environment, salary, public opinion, and personal accomplishment [4,14−16] .
In order to improve the professional self-image of GPs, the government has introduced policies to increase opportunities for title promotion, remuneration, and other aspects pertaining to career advancement [2] . However, there is no evidence that these policies have achieved broad effects.
The effectiveness of the post transfer model in training GPs has been questioned, because training bases were located in modern, specialized hospitals and nearly all trainers were specialists who had limited understanding of the services provided by GPs. Moreover, the rank of specialists at a high-level hospital is superior to that of grassroots GPs. Thus, lack of professional validation and disparity in status and salaries could contribute to the diminished enthusiasm of GPs with respect to their career even after training. In light of this problem, the notion of GPs training other GPs has been proposed. Some local governments have opened high-quality community health service centers that offer general practice. In Guangdong Province, the government has selected a small number of directors of community health service centers in Guangzhou and Shenzhen-the most developed cities-to study GP services in the United Kingdom, United States, and other developed countries, who when they returned to their respective centers applied the knowledge they had accrued.
Communities in which implementation was successful served as models for other communities and training bases. This was not intended to replace but to compensate for the shortage of post transfer training.
As pilot programs of team service were shown to be feasible and effective, the government issued administrative directives for such programs to be expanded so that in each community health service center, GPs work with nurses and public health staff for disease prevention and treatment and patient rehabilitation.
In 2015, the Health and Family Planning Commission of Guangdong Province formally initiated the Family Doctor Service Team Backbone Training Program, in which each city sends a group of students to the training base. Quali ed trainees return to their workplaces and use their newly acquired knowledge to train their colleagues. The training period for the rst group of trainees is a total of 6 months, divided into three stages, including 1 month of theory, 2 months of clinical practice, and 3 months of community practice. Each month, trainees must study at the training base for 5-7 days, and in the remaining time study independently while working.
The program has been running for several years, but there have been no systematic assessments of its effectiveness. To this end, the present study evaluated the impact of the program on the professional recognition of GPs and their services.

Research eld
This study was carried out at the Shayuan Street Health Service Center in Guangzhou, Guangdong Province, the

Demographic characteristics
Of the 63 study participants, 62 completed surveys and one was excluded for failing to complete the posttraining survey. There were 23 GPs, 8 specialist doctors, 21 nurses, and 10 public health personnel (Table 1).
Females accounted for 61.3% of the group; 50% of participants were between the ages of 30 and 40; and 59.7% had a bachelor's-level education. Clinical medicine (43.5%) and nursing (37.1%) were the most frequent academic majors. Most participants had a primary professional title of Junior (82.3%).

Understanding the responsibilities of GPs
Responses in the questionnaires were summarized as six categories: meaning of the term "general", disease treatment, disease prevention, GP service mode, effect of GPs' services on residents' health, and GPs' role in a team.
For the meaning of the term "general", before the training ve participants understood "general" as "having all types of clinical skill"; two as "pro cient in internal and external gynecology and pediatrics"; one as "panacea"; one as "comprehensive"; and the remaining participants did not know. After the training, seven participants responded with "Five 'Wholes'"-ie, the whole process, whole person, whole family, whole team, and whole community; 20 mentioned the whole person; and eight gave whole family and whole process as answers.
The second category was an understanding of disease treatment-that is, that GPs are doctors whose primary responsibility is to treat diseases. This view was held by 31 participants before and by 25 after the training.
Regarding disease prevention, before the training only ve participants mentioned that GPs should do work related to health education and disease prevention. After the training, 19 participants thought GPs should deliver preventive healthcare; six thought they should provide health education; and seven thought they should provide health management and rehabilitation. The fourth category was an understanding of the mode of general practice service. Before the training, door-todoor service and contract service were mentioned by one participant each. After the training, six mentioned contract service.
With respect to an understanding of the role of GPs in patients' health, before the training, one trainee used the term "health gatekeeper" and another mentioned "patient-centered". After the training, seven people used the term "health gatekeeper", four mentioned reducing healthcare spending, and two responded with "healthcentered." For the position of GPs in a team, before training one participant thought GPs played the roles of handymen and archivists, and the others had no opinion on this subject. After the training, two participants thought that GPs should lead the general practice service team, with the remaining participants having no other opinions.

Views on GPs' career prospects
After the training, 52/62 (84%) of participants reported a positive change in their views on the career prospects of GPs in the next 10 years as compared to before the training, representing a statistically signi cant increase (P<0.05; Table 2). Of the 25 participants who thought GPs' career prospects were "Worse than [those of a specialist]" before the training, 13 changed their responses to "Better than [those of a specialist]" and eight to "Similar to [those of a specialist]" after the training. Ten of the 11 participants who thought GPs' career prospects were "Similar to [those of a specialist]" before the training changed their response to "Better than [those of a specialist]" after the training; and 14/18 people who answered "Do not know" before the training changed their response to "Better than [those of a specialist]" post training. Total 6 12 44 62 † "Worse than", "Similar to", and "Better than" those of a specialist.
There were seven reasons for the change in participants' views of GPs' career prospects ( Table 3). The most common reason was achieving a better understanding of general practice service policies during the training (93.5%), followed by recognition of the need to develop GP services (83.9%). The training base's leadership, demonstration effect, improvement of personal skills, performance of the training base, and trainers' enthusiasm were the other reasons.

Professional preferences
To investigate their identi cation with GPs, participants were asked which they would choose to be-a GP or a specialist-if they did not hold their current position. Before the training, 19/62 participants chose GP, 10 chose specialist, and the others chose neither. After the training, 56/62 participants (90.3%) chose GP and 6/62 (9.7%) chose specialist.
Of the 56 participants who chose GPs, 38 gave reasons (9 in total) for their selection ( Table 4). The top three were sense of self-worth, future trends in society, and patients' needs. Of the six participants-all current GPswho chose specialist, three gave a reason, which was a higher salary. Seven of eight current specialists chose GPs, for which the following reasons were given: 1. "A GP can better help and advise the patient because he/she thinks more broadly and has fewer professional constraints." 2. "There is a greater need at the grassroots level for GPs." 3. "When GPs provide primary medical services, they also engage in health management of chronic diseases.
This can reduce medical expenses for the patients and promote their health, thereby improving their quality of life. This is very meaningful." 4. "After years of working as a specialist at the grassroots level, I understand the importance of GPs for patients. It will take time to change from a specialist to a GP." 5. "Because a GP has a more holistic view of health than a specialist, a skilled GP can prevent rather simply treat a disease."

Discussion
This study found that professional recognition of GPs by other medical health professionals improved after a 6-month training course. The main reasons were a better understanding of policy and awareness of the necessity of developing general practice services. The three major reasons for choosing general practice were a sense of self-worth, future trends in society, and residents' needs.
Our results also showed that training can improve GPs' professional identity. Regardless of their current position, after the training 90% of participants chose general practice courses and 10% chose specialist courses. Four of the nine reasons for the former choice were related to self-worth, future trends, skills, and mental pressure; the other ve reasons were related to patients-ie, meeting patients' needs, ensuring patients' health, establishing good relationships with patients, saving patients money, and better serving patients.
According to the Existence, Relatedness, and Growth theory, the rst four reasons can be described as a need for growth, and the latter ve as a need for community or relating to others.
We also found differences in the occupational needs of current GPs and specialists. The sole reason given by GPs for choosing a specialization was a higher salary, suggesting that being a specialist was seen as more conducive to meeting the nancial requirements for survival. In contrast, current specialists who answered that they would choose to be a GP did not mention salary; instead, their responses showed a need for growth and ful llment through relating to others. In China, low salary is the main reason for the attrition of excellent GPs in smaller communities [15] . Academics have called for increases in GPs' salaries based on experiences in developed countries [17] . Our ndings con rm that meeting the survival needs of GPs by offering adequate salaries is critical for maintaining a stable pool of GPs.
Ignorance of policies played an important role in professional identity. The main factors contributing to the change in perceptions of GPs were a better understanding of their responsibilities and an awareness of the need to develop GP services. Through simple training and without any actual bene ts, 84% of participants developed a positive opinion of the prospects of GPs in the next 10 years, believing that they will be better regarded than specialists. Guangdong province has implemented policies to promote the professional status and improve the salary of GPs [17] . Government bodies at lower levels should make efforts to further strengthen the understanding of these policies among GPs and other health professionals.
The present results showed a discrepancy between the intentions of policies and their implementation.
Erroneous perceptions-for example, that GPs are panaceas, have all types of clinic skill, and can act as handymen and archivists-existed 10 years ago. However, some of these views are still held in the most economically developed province of China, including by medical health professionals selected for participation in the Family Doctor Service Team Backbone Training Program [17][18][19] . This suggests that awareness of the responsibilities of GPs has not met policy expectations; and the change in perceptions after training indicates that in the implementation of the policy, the importance of policy education was overlooked.
Training in communities with successful general practice services can promote perceptual change. In this study, leadership ability, feasibility of general practice services, achievements of the training base, and enthusiasm of the training base all had a positive impact on participants, highlighting the importance of including successful case demonstrations in the training. article revision. QH supervised the study and provided guidance, and participated in manuscript writing and revision. all authors have read and approved the manuscript.