Having returned from my three months of out-of-province electives, I settled back into the swing of things at home… at least for the next two months 😉 I was at home just long enough to do some CaRMS interviews for my upcoming residency specialty training, complete my final undergraduate OSCE (a lengthy clinical exam with actors pretending to be patients suffering from a variety of weird and wonderful ailments), and spend an incredible month working with the Program of Assertive Community Treatment (aka PACT), a service provided at home to individuals with severe and persistent mental illness, helping them stay out of hospital and maintain their independence in the community.
March 1 was Match Day, the day where medical students all across the country are informed which specialty program they have been accepted into; or in other words, the day we find out what type of medicine we will be practicing for the rest of our careers. I was beyond thrilled to match to my first choice of Family Medicine – Northern-Remote stream, a specialized Family Med program designed to address inequities in access and quality of healthcare for Canadians living in rural and remote areas, particularly those of Indigenous descent. While every Family Med program across Canada offers excellent medical training, I was drawn to the Northern-Remote stream for its unique decolonizing vision and immense scope of practice. And now, as of July 1, I will be a member of its team!!
“Plan B” theme party on Match Day Eve – Joshua and I showed up as WWOOFers, to nobody’s surprise!
Even after some epic Match Day celebrations, the adventures were not over! Two days after the Match, I boarded a plane along with three other med students, and two days after that, we landed in Shantou, China, a “small town” of only 5 million people in the Guangdong province, nestled on the coast of the South China Sea.
The four of us had the immense privilege of being chosen to participate in an international medical exchange with one of our sister universities. Every day for three weeks, we toured two different hospital wards, ranging from Neonatology to Hepatobiliary to Orthopedic surgery. An English-speaking physician was assigned to us on each ward and would accompany us on bedside rounds of their patients.
There were a number of striking differences in the Shantou hospital wards compared to our Canadian wards, but the most notable by far was the organization of care. In North America, family physicians (known in the past as “GPs”) are the first stop for the vast majority of patients. Sore throats, earaches, slipped discs, period problems, prostate problems, depression, pregnancy… most health concerns can be treated directly by a family doc, but if need be, the patient is then referred to the appropriate specialist for more unusual and complicated health conditions.
This type of healthcare organization, aka with a “primary care” focus, is rare in China, and the vast majority of individuals in China bypass primary care physicians and attempt to access specialists directly for all healthcare concerns. In other words, if you have a headache, you try to see a neurologist. A cough and sore throat? You hope to somehow snag an appointment with a respirologist. Partly this is due to cost: with China’s three-tiered system, individuals are required to pay for most services out of pocket, so patients do not want to risk having to pay a family physician and subsequently pay another fee to a specialist. Furthermore, there is a strong historical component that has cultivated a sense of mistrust towards the idea of primary care.
Several decades ago, the concept of “primary care” referred to farmers in rural areas who received a mere 3 months of training by urban medical professionals, in an attempt to address healthcare access issues for the enormous rural Chinese population (which represented 80% of the total Chinese population during the 1970s and 1980s). While these “barefoot doctors,” as they came to be known, provided some relief to the healthcare crisis, their training and medical expertise was understandably unequal to that provided in tertiary care centres staffed by fully trained physicians. The barefoot doctor system eventually collapsed under economic policies introduced during the Cultural Revolution.
Family Medicine was only introduced as an official specialty in Chinese medical schools in 1999. In 2009, new health reforms were put in place in response to rising public frustrations over difficulties in accessing professional medical care, as well as the steep prices associated with healthcare. The Chinese government instituted a goal of training 300 000 family physicians by 2020; even this impressive number, however, would still only provide 0.2 family doctors for every 1000 citizens (in comparison, consider that there are 1.17 family docs per 1000 Canadians – ~6x more than in China – and that is still woefully inadequate!!)
Some may think that China’s approach to healthcare is actually more effective; after all, cutting out the middle step of a family physician should likely result in faster and better service, right? On the contrary. Since 2009, primary care use in China has decreased, while visits to hospitals and specialist services have increased significantly. And sadly, death from all causes, money spent on healthcare, and inequity between rural and urban health measures have also increased in China. Multiple studies have shown that regular primary care improves health outcomes and reduces time spent in hospital. But unfortunately, in China, people with multiple different health concerns tend to use specialist and hospitalist care over regularly seeing a family physician. Moreover, people with lower incomes tend to have poorer access to primary care services, and therefore are at a higher risk for poorer health outcomes in general.
The partnership between our university and Shantou has been an exciting adjunct in addressing the primary care gap in China. While in Shantou, Canadian Family Medicine faculty and residents were very involved in giving lectures to and leading discussion groups with Shantou medical students and residents.
It was fascinating to discuss both the differences in clinical approaches between China and Canada, but also realize just how many similarities existed between our sites. As one preceptor stated, “We are all just trying to provide the best care possible to our patients.”