Characteristics and Workload of Pediatricians in China

This study was commissioned by the National Health and Family Planning Commission and conducted by 2 organizations: the Society of Pediatrics within the Chinese Medical Association and the PS-CMDA. This national cross-sectional hospital survey covered 31 provinces and 2733 counties in mainland China. Only 118 (4.1%) counties with small populations (<100 people) and no medical services were excluded.

Hospitals were identified from national government records. A total of 54 214 hospitals responded to the survey, with a response rate (R) of 91.76%. The study included all children’s hospitals (n = 76; R = 100%) and all maternal and child health care hospitals (MCHs) (n = 2184; R = 97.5%; Fig 1). The sample of primary hospitals (n = 43 922) was identified by first randomly selecting 50% of the counties in each province and then randomly selecting 20% of all primary care hospitals in each selected county. A total of 4623 primary hospitals were included.

Structured questionnaires were developed by a panel of experts, including epidemiologists, pediatricians, hospital directors, and government officials, to be completed online by senior hospital personnel. It was pilot tested in hospitals affiliated with Shanghai Jiao Tong University. The survey was conducted between June 2015 and October 2016. In each province, a senior member of the Society of Pediatrics within the Chinese Medical Association and PS-CMDA were trained by epidemiological investigators.

In China, a pediatrician is defined as a physician certified by the National Health Commission of the People’s Republic of China and licensed as specializing in medical care for children. Information on pediatricians included age, highest education level (postgraduate, undergraduate, junior college, or polytechnic school), and professional title (none, resident, attending, or staff physician). Pediatricians’ workloads were calculated separately for outpatient care (pediatric outpatient visits/pediatrician/year) and inpatient care (pediatric beds × turnover rate/pediatrician/year). The pediatrician dropout ratio was defined as the number of pediatricians who had left the profession (those who still practiced as pediatricians in another hospital were excluded) in the previous 3 years divided by the total number of pediatricians in the facility.⁹ The number of pediatricians per 1000 children (PPTC) is a common indicator of pediatrician resource availability. In this study, “children” were defined as Chinese children <14 years of age on the basis of the Chinese traditional pediatrician practice and the definition from the Chinese Statistics Bureau.⁹ The pediatrician geographical density was calculated as the ratio of the total number of pediatricians to the county’s area in units of 10 000 km². Similarly, hospital density comprised the ratio of the total number of hospitals to the population number and the area. Data on county size, total population, pediatric population, gross domestic product per capita, whether it was urban or rural, and area in square kilometers were abstracted independently from the statistical yearbook of each county by 2 researchers. We classified the locations of hospitals as eastern, central, and western regions and urban and rural according to the definition of regions specified by the Chinese government. Eastern regions are the most developed, whereas western regions are the least developed.

We conducted a comprehensive description of characteristics of the hospital and pediatricians. The Gini coefficient, the most commonly used measure of inequality, was calculated to evaluate regional inequalities of the distribution of pediatricians in regional child population using the Lorenz curve.^10,11 In this study, weights accounting for the sampling design of the survey were applied in all analyses. All statistical analyses were performed by using SAS software (version 9.4; SAS Institute, Inc, Cary, NC). A value of P < .05 for 2-tailed tests was considered statistically significant.

In 2014, China had a total of 135 524 pediatricians and 54 214 hospitals providing pediatric care (Fig 1). The median PPTC number was 0.41 (25th percentile [P₂₅]–75th percentile [P₇₅]: 0.211–0.79). On the basis of the study, 3 main challenges in the current pediatric care system were found.

The distributions of hospitals and pediatricians were highly skewed, at 2.7 (P₂₅–P₇₅: 0–7.5) and 15.0 (P₂₅–P₇₅: 6.6–46.2) on average per 10 000 km² and 0.59 (P₂₅–P₇₅: 0.43–0.81) and 0.23 (P₂₅–P₇₅: 0.18–0.38) on average per 1000 children. Substantial geographic disparities in the distribution of pediatricians were observed (Fig 2), with a Gini coefficient of 0.61. East coast provinces of China have a per capita gross domestic product twice as high as that of west inland provinces, and the corresponding PPTC numbers are 1.0 and 0.30, respectively.⁹ Likewise, the average PPTC number is 0.62 in urban areas versus 0.39 in rural regions, and the infant and child mortality rates are twice as high in rural areas as in urban regions.¹² 

Most pediatricians (77.2%) worked in general hospitals that provide pediatric services. The trend is similar for the distribution of these hospitals. Tertiary hospitals were concentrated in urban areas (85.0%) and eastern China (44.4%) (Tables 1 and 2), whereas primary hospitals were mainly in rural areas (77.0%) and western China (40.0%). A small proportion of pediatricians worked in children’s hospitals (7.0%). Unlike the pediatric care system, the distribution of MCHs, accounting for ∼15.8% of total pediatricians, was comparatively even. The Gini coefficient of MCH distribution was only 0.20 per children’s population, comprising one-third of general hospitals.

Regarding educational level, 32% of pediatricians had only completed 3 years of junior college or polytechnic school education after high school. Great regional inequalities were also demonstrated in pediatricians’ overall educational levels, with pediatricians with higher education levels clustered in well-developed regions such as Beijing and Shanghai where 47.3% and 37.8% of pediatricians, respectively, had a postgraduate degree (Fig 3). Conversely, 165 counties (6.0%) did not have a single pediatrician with a bachelor’s degree. In rural areas, half the pediatricians had only 3 years of medical training after high school. In tertiary hospitals, 95% to 98% of pediatricians had a bachelor’s degree or higher. In contrast, 50% to 60% of pediatricians in primary hospitals were graduates from junior colleges and polytechnic schools.

Overall, pediatricians in China were young; two-thirds of pediatrician were <45 years of age. Resident, junior, and senior attending pediatricians accounted for ∼20%, 30%, and 40% of all pediatricians, respectively. In the past 3 years, 12.6% of pediatricians (17 022), most of whom were young doctors, had left their jobs. The tertiary children’s hospitals had the lowest dropout rate (5.0%).

The total outpatient, emergency, and inpatient pediatric visits recorded in 2014 (Table 3) were ∼500 million, 91 million, and 38.6 million, respectively. The pediatricians in tertiary hospitals had the heaviest workload, including the highest bed turnover rate and individual outpatient and emergency visits per year (Fig 4).

In the last decade, both the number of patient visits and beds in health care institutions have doubled (Fig 5) in China, whereas that of licensed physicians increased by only 1.5 times. In other words, in a health care reform context in China, although government health expenditure has increased by more than 7 times, physicians’ personal workloads have increased by ∼1.3 times on average.

This study is the first national survey of pediatric human resources conducted in China. Pediatricians’ overall educational level was low, and nearly one-third of them did not have a bachelor’s degree or higher. Despite the health care reform in China, physicians’ workloads have increased. The dropout rate in the last 3 years was higher than 10%, particularly in private and primary hospitals. Strategies may be developed to target 2 key issues: physician training and retention, and structural reform of the pediatric care system.

The PPTC number in China (0.40) was half that in Japan (0.93)¹³ and a quarter that in the United States (1.9),¹⁴ thus lagging greatly behind the average level of developed countries. Each Chinese pediatrician takes care of 10 times more patients than an American pediatrician, clearly indicating the severe shortage of pediatricians in China. The maldistribution and shortage of physicians poses a challenge to the health systems of many countries.^15,–19 

The Chinese government’s goal is to increase the ratio to 0.69 by 2020, necessitating a net increase of 90 000 pediatricians. Many measures have been taken to train new pediatricians. Because the maldistribution of pediatricians is generally combined with socioeconomic disparities,²⁰ these measures may not prevent trained pediatricians from moving to urban areas, and rural areas that need pediatricians the most may continue to benefit little. This is borne out by evidence from other countries; in Japan in 2004, for example, a new postgraduate medical education program was introduced to improve residency training and optimize distribution, but the distribution worsened.^13,17 

The experience of the African Pediatric Fellowship Program has provided a powerful example of how to deal with retention. Approximately 98% of trainees from local hospitals finished the program in an advanced institution and returned to their hometowns to build practice, training, research, and advocacy.¹⁹ Our hospital in Shanghai has been training pediatricians from western provinces of China since 2012. After the training, trainees return to their local hospitals to assume important roles. Unfortunately, the current targeted training programs are far too small and too few to meet the vast needs of the whole country, partly because there are no financial incentive or reimbursement mechanisms for trainees.

Because China is extremely diverse, a one-size-fits-all approach is inappropriate. Based on the high dropout rate in primary hospitals, a targeted location-allocation strategy may be an effective option when recruiting new pediatricians to minimize access inequality and balance supply and demand in the long run.²⁰ However, working in rural and remote areas is not appealing to most pediatricians and, in the short-term, active deployment of existing human resources may be another route to address the challenge. In the United States, for example, the problem of dropout rates was reduced by providing part-time positions targeted at female pediatricians who wanted to balance their personal and professional lives,²¹ and family doctors are also encouraged to take care of children.

When the spread of “medical dispute profiteers” attracted academic and industrial attention in China, the situations in other countries with a similar number of pediatricians were found to be more harmonious between pediatricians and patients’ families. More interestingly, the media coverage on the crisis of the pediatrician shortage in China came from those provinces where pediatrician resources are more abundant. In these regions, more than half of the pediatric workload is concentrated in tertiary hospitals, leading to the perception of a shortage of pediatricians. This is exacerbated by the combination of low fertility and increasing wealth, which has led to increasing demands for high-quality pediatric care.²² The ever-expanding tertiary facilities in pediatric care remain insufficient to meet the increasing demand for better care nationwide. Therefore, the key strategy is to return to the 3-tiered medical referral system with a gatekeeping system like that in the United Kingdom. Unfortunately, many primary care facilities and personnel in pediatric services are broken because of negligence over the past decade, and the availability of secondary pediatric care has shrunk severely.²³ Because the pediatric workload increased in the last decade when children’s numbers remained stable in China, we can foresee that, without gatekeeping, the workload in tertiary hospitals will continue to grow. To rebuild this system, the Shanghai government divided the metropolis with nearly 25 million residents into 5 clusters and is attempting to link up tertiary, secondary, and primary pediatric care facilities to regionalize child health care and optimize the utility of high-level resources. Health maintenance and simple health problems are dealt with at the local level, and more complicated cases are treated at the tertiary level. Physicians at higher-level hospitals take turns to provide services and training in lower-level clinics to boost quality of care. Family doctors are also encouraged to take care of children.²⁴ These approaches are potentially applicable to a larger network across the urban-rural boundary.

Additionally, there is a special system, MCH, covering almost the entire country. MCH is both an administrative and a health care system providing health maintenance and basic health care.^25,26 However, the causes of death and disease spectrum have also changed over the years. Infection has given way to preterm birth or low birth weight as the leading cause of death. The rapid increase in childhood asthma²⁷ and other allergic disorders, attention-deficit/hyperactivity disorders,²⁸ obesity,²⁹ and precocious puberty³⁰ requires new knowledge and therapies that are often foreign even to well-trained physicians. The health care model must change accordingly from a pure medical to a biopsychosocial model. However, most Chinese pediatricians are not yet prepared for this. In Switzerland and the United States, family doctors take care of ∼20% of the child workload.^31,32 Thus, training traditional MCH physicians as qualified pediatricians represents both an opportunity and a challenge.

Furthermore, the physician fee structure must also match the strategy of regionalizing and optimizing the limited resources. In China, there is no referral system among primary, secondary, and tertiary hospitals. Although most of the population is covered by government health insurance, most patients pay a portion of medical costs out of pocket, particularly in outpatient departments and even in public hospitals, and have the right to choose their own provider. Of greater concern are the negligible differences in the already low physician fees between hospital levels. This, coupled with the 1-child family policy, has encouraged families to seek the best care within their reach even for trivial problems. With economic development and transportation convenience, the demand for high-level pediatric care is ever increasing. Many parents choose to attend a tertiary center, which is considered to provide the best care at a low price similar to that of lower-level hospitals. Furthermore, pediatricians’ job satisfaction is disappointingly low because of their low payment relative to other specialties, high workload, and intense patient-physician relationship.³³ Consequently, few medical students want to become pediatricians and 12.6% of practicing clinicians are giving up their professions and moving to other careers. The large income gap between pediatricians and other specialists also must be addressed by both market force and government policies.

Finally, technologies such as electronic medical records, telemedicine, connected interactive medicine networks, and even artificial intelligence may, to some degree, resolve the challenge of insufficient and uneven distribution of pediatric resources and facilitate training.

First, although the R was high (91.7%), a systematic response bias is possible. However, hospitals that did not respond were scattered across the country and across levels, which suggests this is not the case. Second, we did not consider migrant workers. No data were available to estimate accurate numbers of the migrant population at the county level. Because migrants generally move from rural to urban areas or from less developed to more developed regions, the PPTC number in western regions may have been overestimated. However, only a minority of migrants are accompanied by children, most of whom are left behind with relatives,¹⁴ so the number of migrant children is relatively small and unlikely to have influenced the analysis.

Considering the unequal distribution and general low education level of Chinese pediatricians, it may be more effective to reframe the structure for pediatricians than to increase the enrollment of young physicians. With the right policy and emphasis on training, retention, and reform, child health can be further improved to a higher level in the near future.

We thank all contributors who were not listed as authors, including Drs Yuxin Bai, Yu Chen, Zhou Fu, Ying Huang, Xuan Kan, Sitang Gong, Qiang Gu, Fuhai Li, Yonghong Miao, Minna Shan, Furong Shi, Huiying Shi, Yun Sun, Min Tan, Zhiliang Tian, Huaping Wu, Yin Xi, Xiao Zhenghui, Zhenhua Xie, Xindong Xue, Jinghui Yang, Yinan Yang, Li Zhang, Xiaoping Zhang, Haoquan Zhou, Fabao Zhang, and Zhongcheng Luo.

MCH

maternal and child health care hospital

PPTC

pediatricians per 1000 children

PS-CMDA

Pediatric Society of Chinese Medical Doctors Association

R

response rate