4.1 Summary
The study ,in a self-assessment method, suggested that a large space exists in improving the patient care ability, teaching ability, communication skill and coordination ability of GPs in Shanghai’s CHSs, especially the teaching ability.
4.2 Strengthens and limitations
The study had several strengths. Firstly, this study had the largest sample of 2592 GPs, more than half of the total in Shanghai, among the published analogous studies in China. Accompanied with the scientific sampling and high response rate, the data was complete and representative. Secondly, though the questionnaire we used was self-designed, we referred to authoritative ones. The questionnaire had good reliability and validity, with complete content and suitable structure, thus, the results and conclusions should be reliable.
There were also some limitations. The major one was that measurement and recall bias were investible, because the data we used were collected through GPs’ self-assessment. Some more objective ways should be adapted in future’s updated assessment. In addition, the conclusion may not be always right outside Shanghai. It was recognized that GP developed better in Shanghai, where the number of GP per 10 thousand people[14]was far more than that of most other regions in China, especially the western China.
4.3 Comparison with existing literature
4.3.1 Patient care ability
GPs' median score of patient care ability was 80[70-88.75].It was proved that such ability level could meet the daily working requirement[15]. Some analogous studies in China showed the similar results in GPs’ patient care ability[16]. Patient care is GP’s basic ability[17], and is put firstly in both domestic and abroad GP assessments[18].It was also one of the reasons that many GPs hoped to participate in postgraduation training[19][20]. In past GP training, the problem focusing on theory but ignoring practical skills was common[21]. Pan Xiaoyan and et al.[22]discovered that the operating score of GPs in Guangxi Province, China was only 63. Such problem was also prevalent among GPs in England and Germany[23][24][25].
4.3.2 Teaching ability
An admitted criteria were established and used to select eligible GP trainers in many developed countries. In UK, an investigation among specialists in both general practice and education showed that to be a qualified GP, 18 competencies were necessary, among which 6 were related to teaching[26]. In GMC in 2013, doctors are required that “you must be competence in all areas of your work, including… teaching”(p.6)”, “You should be prepared to contribute to teaching and training doctors and students”(p.14)”[27]. Administration as NHS, MRCGP and AMRC also reminded GPs of teaching ability[28]. In China, expert group suggested that teaching ability was one of three first-class indicators of the criteria for GP trainers[29].
4.3.3 Communication skill and Coordination ability
No matter domestic or abroad, communication and coordination ability wasa shortcoming of GPs, though in this study they got a not low score Some countries paid attention to the training and assessment of such abilities[30]. For example, the workplace based assessment(WPBA) in MRCGP was aimed to evaluate a doctor’s performance of professional competence across 13 areas in the workplace[31].
4.4 Implications for research and practice
It is urgent and vital to improve GPs' teaching ability, in order to ensure the effect of GP standardized training and optimize the overall quality of GP training. However, lack of eligible trainers was a big problem, similar to our study[32]. Without accepting any formal GP education, some GPs in china was far away from being a trainer[33]. Interests is the basic of teaching. Our study discovered that nearly 25% GPs were “ unwilling to spend time in teaching”. GPs are busy in work, and the reward of teaching was too little to attract GPs’ interests. In training process, students hoped to get more pragmatic skills, find the way of how to offer superior healthcare in CHS. But in most time, the expected effect could not present, partly due to trainers’ failure in using various teaching methods. The cultivation of excellent GPs needs excellent GP trainers[34]. To improve GPs’ teaching ability, what we need to do first is to inspire their interests, establish teaching performance appraisal and reward system[35]. Upper hospitals and medical colleges could found a GP trainer training center, hold training lectures regularly[36], and infiltrate advanced educational theories and methods into CHS.
GPs’ teaching related variables------participating in GP trainer's training, working in training CHS and teaching experiences, showed positive correlations with the 3 kinds of abilities. This was consistent with the reality. Shanghai founded teaching CHS since 2012. Compared with the non-training CHS, the training CHS must be better in both facility support and GPs' teaching performance. GP trainer's training was on-job education especially for improving teaching ability and popularizing advanced methods. Teaching experiences were also a reflect of better medical care work competence. GPs performing excellent in daily work would be selected to participate in trainer's training on behalf of their CHS. Only after participating in the training and getting a certification, can they teach student in clinical work.
What’s more, GPs who aged from 30 to 39 years old also got a higher score in patient care ability. Many younger GPs were the main force in CHS, and much more eager to learning.
However, it was surprising that GPs who accepted GP standardized training got a lower score in patient care ability and communication skill and coordination ability. Standardized training is a three-year learning. During the 3 years, trainees only spend no more than 1 year in CHS, which may not be their future working unit. Today, such training in China does not pay much attention to communication skill. Despite the same work duration, GPs accepting such learning might have little experiences of working in CHS and are relatively young, lacking of management experience. Communication skill and coordination ability is one of the necessary ability for GP to get patients’ trust and to improve the understand and cooperation within team. Coordination is to solve patients’ health problem in an easiest way within community condition[37], which was also an important work of GPs. So it is suggested to strengthen communication skill training and provide more CHS exercising opportunities in standardized training of GP.